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Medicine | IN PRACTICE

He's willing to be her safety net

A homeless, pregnant and mentally ill woman teeters on the abyss. As an ER doctor he could walk away. But he won't.

July 09, 2007|Mark Morocco | Special to The Times

The Madonna of the Valley was naked except for black boots.

The night nurses had wrapped her in gowns front and back, but she'd pushed them off and slept cocooned in a blanket like a mummy's shroud, only her feet sticking out. I gently shook her and realized she wasn't wearing boots at all -- her feet were slicked black with thick, fine grime. I can't stand walking barefoot on my own driveway to get the morning paper -- how long had she been walking the city without shoes? I did my exam, she smiled at me and rolled back over to sleep, unconcerned.

The night doctor had given her to me, and while the janitors whirred floor waxers in a hurried attempt to renew the ER's scarred floors before the morning lull ended, I was making my rounds to see if the "pass-on" patients actually matched what I'd been told.

Her name wasn't really Madonna, but it wasn't the "Jane Doe" on the chart either. A couple of good Samaritans had seen her wandering voiceless and naked and had brought her to the ER. Her physical exam and lab tests were normal -- except for her mental illness, the common cold of homeless patients. There was only one wrinkle -- she was pregnant.

This was a big problem, but not for any of the usual reasons -- she wasn't having contractions, bleeding or pain. I wasn't even sure she was aware of her pregnancy, as ephemeral to her as her nonexistent black boots. A few minutes later, the tech rolled the Madonna away, awake and smiling, as the day's first ambulance chased the janitors away. I gave her a wave and turned to meet the paramedics.

It's hard to describe climbing the arc of a day as a "single coverage" doctor in an ER -- where a lone doctor stands against eight or 12 hours of ambulance runs, walk-ins, drive-ups and drop-offs. There are more of these ERs than you'd think -- even in a city like Los Angeles -- the only places left where medicine is practiced 24 hours a day, seven days a week. We take all comers, and each patient must be "worked up," stabilized, treated and "dispo'd" -- meaning sent home, admitted to a specialist or hospital, set up with wound checks, suture removals and follow-up appointments.

By the time the Madonna was back, 22 weeks pregnant, I had 15 other patients going at once. The boy with the forehead cut took 45 minutes, a failing nursing home patient two hours, the lady with pneumonia maybe 3 1/2 . By eight hours into the shift, I'd moved close to 20 patients, but the Madonna was stuck.

It turns out no place wants a crazy pregnant lady. Our own hospital doesn't deliver babies, so our psych ward takes no pregnant women past eight weeks. The county evaluation teams wouldn't see Madonna -- because she was already at a hospital with psychiatric facilities. The big county psychiatric ERs asked us to fax them the file, and then just didn't respond.

At 10 hours, my shift was over. I'd seen nearly 30 patients. Everyone had been sent home or admitted to the hospital, except the Madonna. ER docs don't get overtime pay, but I wouldn't give her up yet, and my charge nurse started dialing the same numbers again, hoping that the Madonna's luck was better on the second pass.

An hour after the end of my shift, one of the psych nurses performed a miracle and produced a phone number for the Madonna's brother. He told me that her family had washed its hands of the young woman with the dirty feet and the baby.

In a second, I swung from elation to despair as her brother thanked me -- and told me not to call back. I asked him if he expected me to send her back to the street, pregnant and alone. He was silent. It wasn't his problem anymore. Then the line went dead.

For a second, I understood how a patient wearing a hospital gown and a bracelet gets shoved out the door of an ambulance onto some quiet downtown street. It would be so easy to go home.

I stepped back. The swing shift doctor was working hard, and the place was full. The nurses were changing shifts -- 12 hours gone since I came on -- and across the room the Madonna was looking at me, her doctor, and the noise seemed to fall away.

I looked up at the clock, then down at her real name, and I turned back to the phones.

--

Mark Morocco is an assistant professor and associate residency director of emergency medicine at UCLA Medical Center. He also works at other ERs in Los Angeles and is the former medical supervisor for "ER."

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