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.
In death, Lucy had become part of a set of troubling racial data. Black women are more likely to die from heart disease than white women at all ages; this disparity is more prominent in women under sixty-five. In life too, Lucy had been a walking billboard for health disparities: hypertension and diabetes are far more common in blacks compared to whites, and black women are almost twice as likely as white women to be obese. Together, hypertension, diabetes, and obesity had surely conspired to cause the heart attack that Lucy suffered right before our eyes.
From what I’d seen there and elsewhere, she probably hadn’t been getting the care she needed. Some of that was likely the health system’s fault—impersonal, inefficient, inferior care. But much of it surely stemmed from Lucy’s cultural surroundings—unhealthy diets, less exercise, and a lower likelihood of following medical advice. All too often, patients at Grady delayed treatment until forced to come to the emergency room. By then, it was often too late.
These public health facts and debates were far from my mind at that moment. Instead, I kept thinking about how her chest pain began during an argument with her son. This dispute had ultimately been the trigger, or tipping point, in her rapid descent from life to death. According to the paramedics, he had gotten into some serious trouble.
As I stood next to Dr. Collins while he completed a “death note” summarizing the medical events of that morning, the charge nurse approached us: “The family is in the waiting room,” she said.
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bsp; Dr. Collins looked over at me and back to the nurse. “Tell them we’ll be right there.”
A few minutes later, we stood face-to-face with Lucy’s family. They met us in the main waiting area, where dozens of black people crammed their bodies onto rows of hard vinyl seats bolted to the floor. Pam, Lucy’s older sister, took the lead. Her complexion was a shade lighter, but the resemblance between her and Lucy—broad nose and thinning hair—was evident. They shared a body type too: Pam’s short frame carried 100 pounds more than needed. Behind her stood Lucy’s daughter Wanda, a mid-twentyish, trimmer version of her mother and aunt. Missing was the son who had helped set off this chain of events. Wondering where he was seemed easier than thinking about what Dr. Collins had to say.
“How’s she doin’?” Pam asked Dr. Collins after he had introduced us.
Her wide stare, sweaty brow, and shallow breaths revealed her panic. Dr. Collins paused as he measured his words: “Let’s talk where we can have a little bit of privacy,” he said. “Please follow me to the family conference room.”
Pam and Wanda held hands. They knew this was bad news. I struggled to stay calm as we stepped toward the conference room, knowing that this family would soon be devastated.
Before we could close the door, Pam demanded to know about her sister: “Tell me how she is doing.”
Dr. Collins glanced at his hands briefly. He then looked up to Pam and then to Wanda. Finally, he took a deep breath. I braced myself for their reaction. “I’m sorry to say that things did not go well…” he began.
“What do you mean?” Wanda asked, her eyes pleading. “She’s still alive, right?”
“No … I’m afraid not,” Dr. Collins said softly. “We did everything that we could, but she went into cardiac arrest and died about thirty minutes ago.”
“Lord Jesus…” Pam moaned, her knees buckling slightly for an instant.
“This is … bullshit…” Wanda screamed. “What kind of damn hospital is this?”
By this time, I’d seen enough misery and death to know that anger and blame were natural reactions for many people. But Dr. Collins seemed unfazed.
“We’re very sorry for your loss,” he gently answered. “I can assure you that your mother received the best care possible.” I silently agreed. Everything they’d done here was exactly how I’d seen it work in the state-of-the-art cardiac care unit at Duke. Sometimes medicine is simply powerless against the wickedness of disease.
“This is Tony’s fault,” Wanda said, rapidly shifting the target of her fury. “That dumb ass. Mama told him to stay out of trouble, and he couldn’t keep his stupid ass straight.”
We figured she was talking about Lucy’s son. “Can you tell us what happened this morning?” Dr. Collins asked. “We heard that there was some kind of dispute?”
Pam’s rapid breathing made me fear that she might soon need medical attention herself. Leaning against the wall for support, she managed to compose herself long enough to answer, “Tony … Tony’s her son. He been in a lot of trouble. He was on probation. But almost done. He was at a party last night. Somebody got shot. They arrested him this morning. Lucy … Lucy’s chest started hurtin’ right after they took him away.”
Pam broke down in spasms of tears and moans. Wanda reached over and hugged her. Dr. Collins and I looked at each other, helpless. Though we were standing in an emergency room, and Lucy had died from a medical problem, its context was social. The stress of her son becoming a statistic, another black man locked up, had been too much.
Neither of us could relate. Dr. Collins later told me that he’d grown up in an all-white Connecticut suburb and attended private schools his entire life. The most heartache he’d ever caused his mom was marrying a Protestant girl (he was raised Catholic). Although my origins were grittier, I had always stayed out of trouble.
Dr. Collins answered Wanda’s questions about her mother’s care. He did his best to explain what had likely happened to her heart. By the time he finished, Pam had regained some of her composure. “Can we see her?” she asked softly.
“Certainly,” he said.
We led them to the room where Lucy had been treated. Since the end of the code, the nurses had largely restored it to its prior appearance. At the center, Lucy’s body was covered with a white blanket from the neck down.
We remained outside while they entered. As they approached, a nurse stepped aside. Pam immediately rushed to the head of the bed, while Wanda hesitated and stood back. As she ran her hand across Lucy’s face, Pam leaned over the lifeless body. “Oh Lucy … my baby sis…” she cried out, sobbing.
Wanda’s anger abruptly washed away: “Mama…” she wailed, as she fell to her knees.
I was intensely uncomfortable in the midst of their sorrow, as though I needed to step away and pretend that it never happened. This was the sort of situation our professors didn’t—or perhaps simply couldn’t—adequately cover in their textbooks or lectures. I looked over at Dr. Collins to gauge his reaction, but his poker face gave no clue to his emotions. As sister and daughter moaned in grief, we stepped away and headed to the main area in search of our next patient. There were other people waiting to be seen. We’d done all we could for Lucy, and it hadn’t been enough. I hoped it would be different with the next patient.
* * *
The four-week emergency medicine rotation took me through day and evening shifts in a variety of settings—an academic hospital, a small community hospital, and a children’s hospital. But I spent the majority of my time where I’d met Lucy and her family—at Grady Memorial Hospital, Atlanta’s public hospital and primary trauma center.
Grady reflects the best and worst of American medicine. Founded in the early 1890s shortly after the death of its namesake Henry W. Grady, a prominent Atlanta journalist and businessman, Grady had a core mission to provide emergency care for the entire city. And it has done that over the years, sometimes to national acclaim. During the 1996 Summer Olympics, more than a hundred people injured in the Centennial Olympic Park bombing were treated at Grady. Less than a year before my arrival, a securities day trader in the city’s upscale Buckhead district went on a shooting spree and killed nine people in two buildings. Seven of the twelve surviving victims were taken to Grady. Not long after I passed through Grady, supermodel Niki Taylor sustained near-fatal injuries in a car accident, spending nearly two months there on her way to recovery. If you were shot, stabbed, or otherwise critically injured in or near Atlanta, Grady was the place where you wanted emergency treatment.
From its outset, Grady’s other core mission has been to provide care for the poor. And here too it has received national attention, but not always the flattering kind. During the period of my medical and graduate training between 1996 and 2007, Grady was caught in the vortex of political and economic forces that caused hundreds of public hospitals in the United States to close: rising numbers of uninsured and Medicaid patients, stagnant or decreasing state and federal budgets, and increased competition from private hospitals for paying customers who subsidize charity care. Each year, Grady lost millions of dollars. By 2007, it owed more than $70 million to Emory and Morehouse, whose medical schools supply the hospital’s doctors. Grady was on the brink of financial collapse. And while good doctors like Dr. Collins meant that individual patients, such as Lucy, received top-notch care at Grady, problems were evident. Major publications featured stories about the hospital’s impending demise, the kind that had befallen D.C. General Hospital in 2001 and Los Angeles’s Martin Luther King Jr./Drew Medical Center in 2007.
But at Grady, the patients kept coming. Throughout the early 2000s, the emergency room averaged about three hundred visits per day. More than half of those patients had no insurance; an additional third were on Medicaid. Almost all the patients were black. Despite its shortcomings, Grady remained the best hope for people in dire financial straits.
Even more important to its survival, Grady remained the destination of choice for those with life-threatening wounds,
and the Atlanta area had no shortage of such cases. During this same time period, between 3,000 and 3,500 trauma victims were admitted to Grady each year. About two-thirds of them suffered from blunt trauma—usually a car accident—while the remaining third came in with gunshot or stabbing injuries.
I saw one such victim, Sean, midway through my rotation. I’d been assigned second shift in the trauma wing. At first, things were so slow that Dr. Mason, the faculty supervisor, and Dr. Stephens, the third-year emergency medicine resident, spent several minutes talking about the current NBA season. Gradually, the conversation shifted to medicine. They asked me about my career goals. I told them that I was leaning toward cardiology but was planning to stay in school a bit longer to study health policy or public health. Seeing how difficult Kerrie’s medical internship had been—thirty-six-hour shifts were common—gave me pause about jumping headfirst into that life. I wanted to have a satisfying career without torturing myself.
“Sounds like you’re in the right place,” Dr. Mason said. “Get a degree in public health. Emergency medicine is a good fit with that. Especially for people like us and our community.”
“People like us”—I’d last heard that expression four years earlier, when I stood in a similar position, back then applying to medical school. On both occasions, the focus rested more on my identity as a fellow black person than as a future medical colleague.
Dr. Stephens agreed with his boss. “I thought about doing radiology or dermatology, you know, the specialties that pay a lot without you having to work too hard. But those were kinda boring. And they’re removed from the day-to-day life of black folks. I wanted to get my hands dirty while being in a position to try and make a difference for my community.”
Black Man in a White Coat Page 9
