SCENES FROM A PRACTICE The Doctor and the Prostitute

Their lives couldn’t have been more different. That’s what drew them together.

KATHERINE McCOY WAS A TH1RD-year medical student when I met her. I was the teaching attending physician at Parkland Memorial Hospital, and she was one of the students on our team of three students, one intern, and one junior resident.

Katherine was from a background of wealth, education, and manners. Her family were prominent citizens of Abilene; most of her education had been at private schools, where she had done very well.

There was a long list of extracurricular activities and student honors. Meeting her confirmed all this and more. You could not help noticing Katherine. She somehow made you sit up straighter and speak more precisely. Her clothes, Gucci pumps, and perfect makeup had no aspect of affectation; it just went with the person. She was neither intimidating nor arrogant, but everything she did somehow served as a non-verbal reminder that if we tried a bit harder, we could be better people. Even without these trappings, she would still be considered a beautiful woman-something everyone recognized. We would sometimes forget that she was just as junior as her student colleagues and that she had the same insecurities and uncertainties about clinical medicine.

This was her first clinical rotation, the first real laying-on of hands, and I worried that the destitute patients at Parkland would be a shock. To be sick and poor amounts to more than the sum. Frustration, anger, humiliation, and ignorance quicken the rot of disease, and by the time the disease gets to Parkland, it’s often late and desperate. Delicate conversation and mild manners might appear professional, but to many Parkland patients, they are condescending. Katherine was in foreign territory. It was as though she were having a coming-out party at a downtown Greyhound bus station.

We gathered in the morning after that first night of call to review the newly arrived patients. Katherine presented her first patient.

“Samantha Brown is a 23-year-old black woman, intravenous drug-user, admitted with shaking chills and fever. She was well, until the day of admission, when she had the onset of severe chills, nausea, weakness, and a fever of 104 degrees. She shoots cocaine daily and has previously been admitted with fever, thought, after full evaluations, to be an allergic reaction.”

What an introduction to clinical medicine. “Shooters” with fever are commonplace at Parkland. Frequently it means infected heart valves, a long hospital stay, and a dubious outcome. If I could have arranged it, Katherine would have been given some nice grandmother with diabetes and a little heart failure. A toe in the water rather than a cannonball.

“OK,” I said, “tell me the rest,” noting that she seemed nonplussed. In fact, she looked better than her fellow students, who were gray-green after a sleepless night, garbed in rumpled scrub suits and scuffed Reeboks. Katherine looked fine.

“Well, she couldn’t give much history,” Katherine said, “since she was delirious. Un physical examination, her blood pressure was 90/60, pulse 120, and temperature 104. There was a soft, systolic murmur along the left sternal border, rhonchi in both lung fields, some tenderness in the lower abdomen, and large ulcers over the dorsum of both wrists. Other than the delirium, the neuro-logic examination was normal.”

Katherine continued with the laboratory evaluation. “The hematocrit was 33 percent, the white blood cell count 22,000 with a shift to the left, and the rest of the blood work was normal. The chest films showed bilateral patchy infiltrates and a slightly enlarged heart. The electrocardiogram was normal. We did a lumbar puncture, which was normal.”

It was a very concise presentation. Katherine knew we had seven patients to review. She was pleased to lead off but didn’t steal time from her colleagues. “Let’s go see her,” I suggested.

The processional into the room was to the strains of “Good Morning America” playing on the overhead television. Samantha was not visible. She appeared as a mass of twisted blankets. We peeled some away to find her head. She averted her eyes and looked off to the floor. Samantha had a Marine crew cut and a sheen of sweat on her forehead. When she did dart a look at us, there was a flash of white sclera and white teeth, startling against her very black skin-undiluted black, purple black.

“She’s better this morning,” volunteered Katherine, trying to break Saman-tha’s silence to our greeting. “Her temperature is down, and she’s oriented now. She still complained early this morning about some abdominal pain and nausea.”

I continued the unveiling. There were indeed bilateral pneumonia and two large ulcers on the backs of her wrists. These were desperation ports, since all other veins in her arms and legs were reduced to knotted strings from repeated injections.

In spite of all this, the veil could not hide the fact that Samantha was a beautiful woman and sensuous even in her distress. While I continued my examination, the rest of the team adopted the Parkland slouch-leaning against the walls, foot up on a chair, scribbling on the scutwork board, and fighting fatigue. All but Katherine. She watched Samantha intently, occasionally flicking her gaze at me. Katherine seemed tense, even afraid. There was little conversation with Samantha. “Yes” was a grunt and “no” a wag of the head. We retired to the hall to wrap up.

Our working diagnosis was bacterial endocarditis of the right side of the heart, which had sent infected debris from the heart valve to her lungs. The blood cultures would probably be positive, and in the meantime, she was getting appropriate antibiotics. An echocardiogram was scheduled for later in the morning, and the cultures might be out that afternoon. We moved on.

Over the next few days, our suppositions were confirmed. The blood cultures were positive, and we began to learn a little more about Samantha. “Does she work at night?” I asked one day, trying to be careful with my diction and what I presumed were delicate sensitivities.

“Oh no,” said Katherine, “she doesn’t have a regular job. She’s a prostitute and has been since she was 12.” So much for delicate sensitivities.

“What about her abdominal pain and nausea?” I asked.

“Still a problem,” said Katherine. “We did an abdominal X-ray, which was negative. She seems worse in the morning. Lots of pain and lethargy, but she improves during the day.”

Now there was a familiar verse. “Does her man visit her at night?”

“You mean her pimp?” asked Katherine.

“Yes, sometimes they sneak in and shoot up their girls. Check that out, and also, let’s get an ultrasound of her abdomen to see whether she might have a tubal abscess or something else giving her pain.”

The next day brought a heavy dose of embarrassment and contemplation. Sam-antha was pregnant. The ultrasound showed an eight- to nine-week fetus. Heads were down and toes scuffed the tile. We were all astonished that a condition for which Samantha was so much at risk should have been discounted at the outset. We all assumed that a prostitute could not, would not, get pregnant. The combination of cocaine, bacteremia, potent antibiotics, and abdominal X-rays made it unlikely that this would be a successful pregnancy. Katherine suffered more than her fair share of our collective guilt.

“No mind,” Samantha said. “Lost the last three. Gonna lose this one.” She did, about one week later.

As the days passed, Samantha improved. What I had first interpreted as arrogance and anger proved really to be an intense shyness. In her world, to be shy was to invite brutality. Protection came only from a costume of strength. She used many disguises. The crew cut, we learned, was to accommodate a variety of wigs or for those who liked their sex “kinky.”

Katherine and Samantha seemed to circle each other closer and closer. On two occasions, I could see them talking together. Heads close, short laugh, long pause, a few words, an affirmative nod by one or the other. It was a curious private alchemy, and I could only speculate. It seemed to be two women, each aware of the other’s beauty, and perhaps each in awe of the other’s life experiences.

Not opposites, more like anagrams.

I, and I suspect, the rest of our team- all men-felt like intruders. On rounds, Katherine became the conversant with Samantha and stayed close while the rest of us held back. They seemed to be answering for each other and shared the determination to get Samantha well and out of the hospital. Katherine showed the courage that will make her a fine physician.

Samantha did get well and was discharged after a long hospital stay. I still think about this episode, this reminder that teaching means taking second-hand pleasure. The secret shared between Katherine and Samantha happens to most clinicians, and as with these two, it is an unpredictable communion. A sip from each other’s cup-solemn, joyful, and moving.

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