I was three days late. I had considered the possibility of Tiny leaving AMA from the convalescent home, but I was still saddened when the head nurse told me that he had left on the first of the month and that he would not be allowed back. I had believed Tiny would welcome the chance to be housed and clean, but now, three days into the month, as I drove around looking for him, I realized just how naïve I had been.
Looking for a homeless man on the streets of West Hollywood is a bit like searching for a needle in a haystack, but Tiny, standing at just over seven feet tall and weighing nearly four hundred pounds, was one huge needle. With a little luck, I thought I could locate him. Just what I planned to do then, I had no idea.
As I drove back to the site where the UCLA Mobile Clinic had picked him up, I recalled the events of that day just three weeks before. One of his friends, “Fats,” informed me that Tiny could no longer walk and that no one could get within ten feet of him without retching.
Fats drove with me to the park where Tiny lay. He was hard to miss, sprawled on the grass, his jeans splattered with dirt and feces. I had approached cautiously. The smell was overpowering. I told him that his friends wanted me to look him over, to which he nodded his consent. He began to roll up his pant leg so that I could visualize the injury. Peeling off the toilet paper wrap, yellowed from pus, revealed what had been and remains the worst wound I have ever seen: the visible striations of the tibialis anterior were covered by a thin dirty film; thick yellowish plaques bordered the scaly, blackened flesh. The ulcer stretched from just below his knee to his ankle, which on a man seven feet tall is nearly a foot and a half. The smell was beyond decay—it was death. A fellow student and I quickly debrided the injury as best we could, dressed the wound, and with care and help, loaded him into my car.
Now, as I walked through the park, I realized just how angry I was. No one had seen Tiny. “Tell him I am looking for him,” I said. How could he do this? How could he turn down this opportunity to get well? After all we did, after all I did—drove him to the hospital, waited until he was admitted, pleaded with doctors not to take his leg, visited him in the home—how could he do this to me? And this last thought stopped me cold: when had this become about me?
Working on the streets of West Hollywood with the Mobile Clinic was an enjoyable diversion from medical school, but the streets were his life. Maybe it was something that I just had to accept. But no, I would not give up. I wouldn't let him go just because he was homeless and I could make myself believe that it was a choice he made. It didn't have to be like this. Yes, I thought, I need to understand where he is coming from, but no, I don't have to accept his fatalism.
As I left the park, I revised my message, “If you see him, tell him that I hope he's okay.”
An hour later, with the sunlight fading, I was nearly ready to give up. I was heading towards the freeway when I saw Tiny, the near giant, slouched on a bus bench on Vine just south of Hollywood. I parked and walked over.
“Hey,” I began.
The color that had been returning to his face in the home had quickly disappeared back on the streets. The 72 cm PICC line that had been inserted on the second day after he was admitted was gone, replaced by track marks.
He sighed and sniffled.
“I am not mad.” I said, “I was for a while, but I'm not now. I just want to know if you are okay.”
We sat there for a while in silence.
“They had too many rules.”
“Last week,” I laughed, “you got all the bacon you could eat. You said they were treating you great, what changed?”
“I don't know. They were getting on me. I left on my own terms. They weren't going to kick me out.” And then the big man broke. His massive hands covered his face and he began to cry. “I didn't shoot it all,” he said. I raised my chin towards the absent line. “I wouldn't do that. I wouldn't shoot through that, so I pulled it out.” He began to sob, “I don't want this. I'm sorry. I don't want this.”
“Okay. It's okay.” I hoped that it would be. “What do you want to do?”
“I want to go back.”
“I already asked. They won't take you back. We're going have to start over.” I paused. “Can you do that?”
He was silent for a long time. With his eyes closed he nodded.
We got in my car and drove back to the hospital, where we waited for hours in the ER, where people whispered and moved away, where nurses treated him roughly and with contempt. “Weren't you here for this already?” they asked. He was unwelcome, and I began to understand how someone would want to leave. But he didn't. We didn't.
Tiny is in a new board and care home now. And when I take him out to lunch back to his stomping grounds and he yells to old friends with pride, “I'm clean—four months!” I realize that sometimes clinical doesn't always mean a hospital or even a clinic, sometimes it means just sitting on a bus bench listening and waiting for the moment that someone is ready for change.
The Arnold P. Gold Foundation, Inc., is a public, not-for-profit organization founded in 1988 to nurture and emphasize in medical school and teaching hospital programs the medical profession's time-honored tradition of caring. The Foundation believes that compassion and respect are essential in the practice of medicine; that cooperative relationships between and among caregivers and patients increase trust and enhance the healing process; and that medical role-model practitioners who embody these values deserve support, encouragement, and recognition.
The Foundation supports 26 diverse and innovative programs throughout the United States and in other countries that are designed to foster humanism in medicine. In 1999, the Foundation instituted the annual Humanism in Medicine Essay Contest as a way to encourage medical students to express themselves through reflection about their experiences.
Any student from an accredited medical school may enter. Cash prizes are awarded for winners of first ($1,000), second ($500), and third ($250) places and up to ten honorable mentions are awarded.
The theme for the 2001 Humanism in Medicine Essay Contest was “The Clinical Experience That Taught Me the Most.” The Gold Foundation received 358 submissions from more than 110 allopathic and osteopathic medical schools. Winning essays and honorable mentions were selected by a distinguished panel of judges. Academic Medicine is pleased to publish the top three winning essays from the 2001 contest in the September, October, and November 2002 issues. The essay by the secondprize winner, Walter Coppenrath, appears here.
Winning essays are also published on the Foundation's Web site: (www.humanism-in-medicine.org), and in The Foundation's DOC newsletter. For further information, please call The Arnold P. Gold Foundation at (201) 567-7999 or e-mail: ([email protected]).