Renegade M.D.: A Doctor's Stories from the Streets

Renegade Press

Copyright 2023

All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review.

Note: Unless otherwise stated, all patient names are fictitious,

and in many cases, identifiable details have been changed.

ISBN: 978-1-66789-161-3 (print)

ISBN: 978-1-66789-162-0 (eBook)

Table of Contents

Introduction

1—Leprosy

2—To Stent or Not to Stent

3—Pedro

4—First Patient of the Day

5—Nec Fasc

6—Tragicare

7—Elbow Fracture; Big Dude

8—Free Will

9—Free Will, Part 2

10—The American Dream?

11—Daniel’s Story

12—Cookie

13—Missing Paris

14—Treat, Don’t Incarcerate

15—It’s Not Okay with My Soul

16—New Kid; Good Doctor

17—Tina Marie

18—Sometimes Rock Bottom is Death

19—Tragedies and Triumphs

20—Mourning the Gentle Souls

21—Let’s Keep the Gravely Disabled out of the Grave

22—Behind the Muddied Glass

23—Mental Illness, Meth, and Skid Row: Making it Happen

24—I Know Death; Hope for Haiti

Excerpt from This is Haiti

Introduction

When I started telling stories to my colleagues about some of the patients I treated while working with PEH (people experiencing homelessness), one of my best friends suggested I write them down. So, I did. I also started responding to op-eds in the Los Angeles Times and writing letters to the editor about issues relating to the homeless. In 2007, I asked the then-editor how to submit an op-ed of my own, and I submitted my story about William. When it was approved, I realized I had something to say, and people liked reading my stories. In the ensuing years, the situation for PEH hasn’t changed much. There is more research proving the importance of supportive housing, and homelessness is given more attention by politicians and the media. But tens of thousands have been living on the streets of L.A. for decades. We have made some strides—more money appropriated, more outreach workers and street medicine teams, more interim housing—but the suffering is the same, especially for those struggling with severe mental illness.

Covid-19 gave those of us working with PEH an excuse to get more organized, and in some cases, more resources became available. Fortunately, Covid-19 didn’t inflict its greatest assault on PEH unless they were in shelters. At the start of the pandemic, I sent an email to the handful of street practitioners I knew, suggesting we meet weekly to compare events and protocols. We started having regular, ongoing meetings that allowed us to learn from one another.

Because of Covid-19, we were able to use hotels to get more at-risk folk indoors. Brilliant! But the severely mentally ill were still in the streets, still eating out of garbage cans, filthy, yelling at hallucinations, getting incarcerated and released to the streets again and again. In recent years, owners of board and care facilities for the mentally ill are selling because they are not fairly reimbursed. For those who need advanced care and support, there are few such facilities. After PEH are hospitalized for mental illness, they are usually released back to the streets because there is nowhere for them to go! We need to focus on housing that heals, finding places for our most vulnerable so they’re able to fully recover.

When I started practicing street medicine in 2007, I remember walking along the Santa Monica Promenade one morning. I grew up in Brentwood and Santa Monica, so this was my backyard. The new mall adjacent to the Promenade was built while I was in junior high school, and the Promenade itself while I attended college. It soon became the westside’s weekend hangout for movies, shopping, and dining. That morning, it was sunny and quiet but busy with locals getting their breakfast or shopping in the swanky shops. Also, PEH were hanging around. I noticed an older woman, who looked to be in her eighties but probably was younger. Living on the streets ages people quickly. This woman didn’t look unkempt, but she wore a long, flannel nightgown with pink flowers, and ratty slippers. She was asking for money.

Hi, I said. Do you need any medical help?

She squinted in the bright sun. Are you gonna give me money?

No.

Then leave me alone!

I thought of my grandmother, who had recently passed away in her nineties. She had been quite the matriarch of my dad’s large, Persian-Jewish family. My father and his siblings took great care of Grandma and Grandpa. Grandma developed dementia after my dad passed, and she required round-the-clock care. If my grandmother had wanted to panhandle on the Promenade in her flannel nightgown, I would have picked up all four feet, nine inches of her, tucked her under my arm, and thrown her into my car. My aunts and uncles would have all done the same in a heartbeat.

I realized this cantankerous woman before me WAS someone’s grandmother, mother, sister, or aunt. She might as well have been mine. I would never allow my family member to live on the streets (and had to face this possibility when both my mom and then, my sister, became incapacitated). Why do we, as a society, allow it? Americans like to think that here, we have free will. But why can’t we recognize that some people lack the ability to make rational decisions for their well-being—like children, those with intellectual disabilities, and those who are demented? We recognize their inability. Why can’t we give the same urgency of care to those with severe mental illness?

For my entire career as a doctor, I have strived to take a stand, so that all suffering from demons can be cared for—just like my own grandma, mom, and sister. I hope by reading these stories, you’ll recognize the shared humanity of these most vulnerable members of our society and join me in my efforts to treat them like family.

For all my patients. May their voices be heard!

1

Leprosy

Leprosy! my mentor, Steve, announced.

We stood next to each other in a five-by-ten-foot room with a cement floor, two walls of plywood shelves filled with various medications, and one bed behind a makeshift curtain made from an old, ratty sheet.

We stared down at the man’s feet—a red, white, and greenish menagerie of flesh.

Steve called out for Anne, a surgical nurse. Assist me, por favor. He straightened up and sweat gleamed from his high forehead. A thirty-year-old engineer who had trained as a physician’s assistant, Steve was short, with a full moustache and a love of Christian music. We listened to his cassette tapes on our drives to and from Mexico.

What do we have? Anne, an industrious volunteer, poked her head in.

The patient was sitting on an upside-down bucket being used as a stool. Around sixty, he had a tan, leather face. On his lap sat a cowboy hat, which had left sweat-soaked hair plastered across his forehead.

Debride! Steve answered cheerfully.

It was 1986 and I was eighteen years old, in my first year at UCLA. I arrived with Steve and other volunteers. We had traveled in an old brown van, crossing the border where Mexican agents easily waved us through, past the large CaliMax market, then continuing toward downtown. Tijuana had a distinct smell, like grilled meat mixed with manure. Often, we’d pick up people along the narrow, bumpy road to the clinic. In the sweltering heat of summer, packing what felt like an entire, sweaty village into the van annoyed me; later, I understood this was partially how the group served the community—by bringing them to church. That morning, we had arrived early at the squatter site, el dumpay, our made-up Spanish name for the dump. The clinic was literally on top of a hill above a valley of garbage.

Anne pushed aside the sheet-curtain and moved next to Steve. She seemed able to read his mind and would often start working on patients without direction.

I stepped aside, planting myself in a corner but close enough to observe. I was grossed out but excited at the same time. I didn’t know anything about leprosy other than it was a skin disease discussed in the Bible. And here was Steve, helping a leper, just like Jesus. How do you treat this? I asked.

Steve explained the process of debriding, removing dead and infected skin. This, along with antibiotics, would allow the infection to heal. Then he asked Anne about dinner.

All day, patients would line up in the heat outside the clinic. They came for various reasons: diabetes, hypertension, infections. But the most coveted item was Beeks, aka Vicks Vapo Rub. The windows of the clinic were covered with bars, and the patients yelled through them: Doctor Esteeb, Beeks!—the panacea for all that ailed them. They lived in shacks made from scraps of wood and fabric. They were the poorest of the poor and spent their days picking through the heaps of trash looking for recyclables or things for their homes—both adults and kids. I had heard there was an outhouse behind the church, which was behind the clinic, but after checking the facilities out, I had decided to try and hold it in all day.

Steve started cutting away sections of the man’s infected feet. Anne handed him supplies and took away the pieces of tissue he handed back. My heart was pounding. A substantial chunk of the man’s big toe came off and yet, they continued to review dinner choices—all part of this flowing, orchestral performance.

I felt completely engaged and alive. I had wanted to be a doctor since I was twelve years old. Finally, I was experiencing what I had been preparing for with all the science and math classes I’d taken. My way to science had been through math, with the assistance of people like Mrs. Gaspar, my third-grade teacher. I used to stay after class to help her clean up because my parents came home late from work. I loved Mrs. Gaspar. She was short and stumpy, with dark hair cut above her ears. We called her Mrs. Penguin because of the way she walked, but she always treated me with respect and like an adult, which I loved. When I asked why she had put me in Math 1, the remedial group, she said Math 2 was too crowded and she didn’t want me to be overwhelmed in Math 3. Although I hadn’t been a very confident kid and often worried about who liked me and who didn’t, I was confident about school, and my abilities. I asked Mrs. Gaspar to let me try Math 3. She didn’t question me or say, What do you know? You’re just a kid, like my mother would have.

My mother could be mean or degrading at times, competing with me for my dad’s attention. As an adult, I can see we lacked that special, mother-child bond. I was closer to my dad, and though I knew he loved me, I didn’t feel loved. He didn’t tell me he loved me and wasn’t very cuddly. And so, my entire life I chased love. When will someone love me? I persistently thought. Although Mrs. Gaspar wasn’t lovey-dovey, she listened to me. I felt heard. In many ways, Mrs. Gaspar launched my scholastic career because she saw my ability and gave me a chance to prove myself. When Brentwood Elementary became a science magnet school, I discovered I liked science even more than math, and I was on my way.

I excelled in Math 3 and in school overall, which pleased my father. Being smart was common ground we shared because he had been a scholar, so to speak. Dad was born in Iran and had a master’s degree in engineering, completed in the United States. When I mentioned the volunteer trip to Mexico, Dad had been suspicious of Steve at first. Eventually he acquiesced, but to be honest, I was my own person by then. I made my own decisions. No one helped me get into college, like parents do now. I picked my own classes, joined a sorority, chose my specialty, studied for the MCATs, and chose medical schools all on my own. From a young age, I was fairly capable and independent.

Susan, Steve said. Would you find us some more gauze, please?

And maybe some saline, Anne added.

Sure. I edged around the patient’s cot, never looking away from the bloody proceedings below his knees.

The clinic was disorganized, having been set up impromptu and run by a rotating crew of volunteers. As I rooted through the supplies kept on the shelves, I noticed a huge book, a 1984 edition of PDR (Physician’s Desk Reference), which lists all medications and their uses (a highly valued source before the Internet!). I would remember that book, eventually studying it front to back to organize the supplies at hand into a system, and to educate myself about ways to best use what was available. But for now, I scanned the shelves for a box of gauze and a clear bottle of saline.

I had first traveled to the dumpsite in Tijuana in high school during an Easter break. A dozen teenagers and some college students had signed up through the Brentwood Presbyterian Church to build small houses for the locals. This was my first experience of poverty. I grew up on the Westside of Los Angeles. Up to that point, I didn’t know about good neighborhoods or bad neighborhoods. I had never been downtown, or to east L.A., and definitely not to South Central.

Back in the makeshift exam room in Tijuana, I handed the medical supplies to Anne, who took them without taking her eyes off the now deformed foot. Steve was busy soaking up blood and reached for more gauze. I wasn’t sure I had found enough.

If you could wrap him, Steve said to Anne, handing her the final roll of gauze before he moved on to the next room, the next patient.

In the 1980s, I had seen commercials with impoverished Ethiopians, but it didn’t hit home until I saw it with my own eyes. But in Mexico I also discovered something about resilience. Amidst the trash and deplorable conditions, the children at the dumpsite still laughed and played. They raced around the clinic, waiting for their parents to be seen, or waiting to be seen themselves for conditions that mostly would have been considered routine in the United States. For them, minor health problems often persisted and caused much suffering. But still they played!

As I watched Anne gently wrap the man’s feet, I remembered what a high school friend said to me, trying to convince me to join the trip to Tijuana. Do something for someone else for once in your life. And she was right. I had been self-centered and often worried about how I looked or who liked me.

I started going to the clinic with Steve every Saturday, where I watched him use humor to put everyone at ease. I quickly began to learn Spanish, as I had taken French in high school, and I started to understand most of Steve’s jokes. The patients loved him. I remember one Saturday we saw Hugo, who was a regular. He was in his forties, quite overweight and always very dirty. Due to poor circulation, his legs had venous stasis, which causes swelling and skin breakdown. This is common in diabetics and people with hypertension, and he certainly could have had both. Because of the poor circulation, he would get large ulcers, or wounds, on his legs, and he’d come in for treatment when things became unbearable. That Saturday, I carefully unwrapped the bandages he’d made with paper and a bandana. I blinked at what I saw underneath, almost not believing it. One of the wounds was teeming with maggots. By then, I had learned to not react to things that were gross. Hugo’s eyes shifted away in embarrassment and at that same moment, Steve popped over to see what I was doing. He saw what was happening and without missing a beat, said, Mm mm, lonche (pronounced lawn-chay). Lunch!

We all burst out laughing, including Hugo, his wife, and several other patients lined up outside and watching through the barred window. Our laughter increased until some of us were in tears. From Steve, I learned the value of humor in making and keeping a connection with patients. As we finished and Hugo sat up, he gave a modest smile, although he’d been sweating throughout the procedure, often gripping the sides of the cot.

During my trips to Tijuana, these aspects of my identity up to that point—my love of science and desire to be a doctor, that first exposure to poverty by seeing the effects of famine on Ethiopian children, and maybe, a personal need to be appreciated and have a direction—all combined to crystallize into what would become my life’s purpose, treating the impoverished. I made humor an important part of my bedside manner, and it felt good to bring laughter and ease to patients. If people living in poverty could still have a sense of humor and play, then why couldn’t I? Besides, I easily related to patients. They seemed like regular folk to me, each patient a challenge to treat medically and communicate with effectively. I loved the challenges that showed up at the clinic in Mexico and later, in my own practice on the streets and in clinics and hospitals around Los Angeles. In my family, I sometimes felt unloved and unheard, but on top of a pile of garbage in another country, I loved and was loved back. Because of these early experiences in Mexico, I made the commitment to become a doctor and focus on patients who experience the worlds of poverty and injustice.

2

To Stent or Not to Stent

Pronounce her, the resident said. He was tall and bright-eyed, a second-year resident—which meant he had one more year of experience than I did. Most of the time he was an asshole, arrogant and stand-offish. But now, his hands were shaking.

I was twenty-six years old, a family medicine intern rotating on the gynecology team at Harbor-UCLA Medical Center,