I train at an inner-city hospital like many other prominent emergency medicine (EM) training programs in the United States. Our immediate community is—bluntly stated—a poor one. A third of the inhabitants live below the poverty line, and the median household income is half that of the rest of the state and half that of the national average. The city, however, is flanked by some of the wealthiest communities in the state as well as the country. I find this ironic but not surprising. Take any major city in the United States: you will find a zip code shocking for its high crime rate and low household income only to share borders with zip codes boasting quite the opposite. That is the grandeur of suburban sprawl, I suppose, but not the topic of this piece.
I know the divide exists, but every once in a while I am surprised by the imbalance of haves and have-nots in our emergency department (ED). I was reminded of this one day during the swine flu surge of 2009. I had a hacking cough from Halloween to Christmas, and one day it was worse than most. I picked the next-to-be-seen chart from the bin. Chief complaint: cold foot. I thumbed through the chart as I walked down the hall. The street name caught my eye as I flipped past the demographics sheet: Champagne Lane.* I grinned as I knocked on the door. The elite address is not one of our usual visitors, and I thought, “Ah, here is a patient with whom I can have a reasonable, mature conversation.”
My instinct led me astray, and I did not grin for long. A stern, elderly woman was sitting up in the stretcher. She sported standard issue Talbot’s weekender wear: olive colored polyester pants with a shell colored sweater. The right half of her Hush Puppies shoes was on the floor along with her sock. Her white hair was cropped, and her cool gray eyes pierced me from behind her brassy eyeglass frames. Her face was wrinkled, tight, and drawn. The room had a potent scent; not the usual combination of foot ulcer and homelessness, but rather heavy floral perfume and caked facial powder. For a moment I thought it was my fourth grade teacher and I would be forced to recite my times tables.
If only my task with this lady had been so easy. Her husband smiled and said with relief, “Look dear, help has arrived.” The patient still looked annoyed and said, “Finally a nurse! I’ve been ringing this button. Okay then, I need a blanket, a glass of ice water, and if you could call Dr. Langston, * my vascular surgeon, I would really appreciate it.” I explained to her that I was the emergency physician and would conduct my own history and exam; I would be happy to give her surgeon a call once I had some objective information. This barely seemed reasonable to her. Right about then, I had a brief coughing fit and apologized for being under the weather. The husband empathized but the patient snapped at me, “You’re sick. You’re disgusting. I’d rather you not touch me.” At this point I really wanted to slam the door and walk out, but the husband ameliorated the situation. So I did an admittedly cursory exam and left the room. I called the surgical residents who ultimately admitted her. Every physician or nurse who entered that room confirmed that dealing with her demands, severe tone, and general condescension was an unpleasant experience.
A few minutes later, I picked up the next chart. It was that of a young man, Oscar*, who presents to our ED every so often; not truly a “frequent flyer,” but a familiar face. This time it was chest pain. Had he used cocaine today? No? Well, okay, maybe really early that morning. I continued to cough; so much so that my eyes started tearing. I displayed a learned response from my last patient encounter and began to retreat. However, crack cocaine–addicted Oscar touched my arm and said, “Doc, you don’t sound too good, why don’t you take it easy. You know what, I feel alright now.”
You, me, and all of Champagne Lane probably paid for Oscar’s visit that day, and the 10 prior ones as well as the next 10. Some days I want to write a piece just on that, but that day I marveled at Oscar. Our impulse as physicians may be that the patients who are as educated, learned, or even as privileged as we are, are the ones we relate to best. However, this profession teaches us that empathy and patience have nothing to do with degrees, wealth, or sophistication: care and consideration often dwell where we least expect.