When Tay, our brilliant front-office manager, brought back the charts, we would break students into teams and send them out. Then, quiet would fall over the banana room, broken only by the murmur of a director making lab callbacks.
The quiet was brief, because before long our volunteers would start rocking up with questions. “How can I schedule this patient for an eye exam for his diabetes?” “Do we have any more of those giant Q-tips?” “Is there a counselor here tonight?” “My patient has a colostomy, but he can’t afford colostomy bags. Can we get him colostomy bags?” (This question precipitates a brief bout of cursing the doctor or system that will do a multi-thousand-dollar surgery connecting a patient’s colon to the wall of his abdomen, but won’t provide him with plastic bags to catch his shit, then a furious discussion of whether we actually have colostomy bags and where they are, and why isn’t his surgeon following him anyway?) “What do I do with this urine sample?” “Do we prescribe Klonopin?” “Can you look at this rash?” “This guy just had a stent put in his heart and they sent him here for follow-up, so what am I supposed to do with that?” “Do we give out glucometers?” “I think this X-ray report says this guy’s back is broken.” “Does anybody speak Spanish?”
The directors would field these questions, and welcome the doctors as they rolled in around five, and then the students would present their patients to us. We would coach them a little bit on how to present to the attending, bring up options for their differential diagnosis, and remind them to get the patient’s height and weight. We would also field any emergent issues: If a patient had chest pain, we’d quickly make sure they didn’t need to go to the ER. If somebody was bleeding, we’d supply gauze. If a biopsy was going to be done, we’d get the equipment. If somebody was about to have their lights turned off in their apartment, we’d refer them to the front desk for utilities assistance. If somebody had a child, we’d refer them to be evaluated for Medicaid eligibility. If a student was crying, we’d talk quietly with them. If somebody needed a medication they couldn’t afford, we’d help the student start filling out the forms to apply for assistance. If somebody needed a chest X-ray, we’d look up the price, e-mail Dr. Beach to approve funding, and make a referral. If there was a patient in the waiting room who didn’t have an appointment, one of us directors would triage them to figure out how urgently they needed to be seen.
After the student presented to us, we’d send him or her off to present to an attending doctor. The attending and the students would see the patient together, then come back to the banana room again so a director could give and document medication samples or donated meds, sign the chart, and schedule a follow-up appointment. The student would then head off to a laptop to finish writing the note on the patient, which we directors would also double check.
Practicing medicine as a student director at St. Vincent’s meant having a fund of knowledge not just about disease and treatment, but also about the clinic itself, the social systems in our area, and the emotional experience of our volunteers. It meant keeping our patients and the clinic afloat, and trying to make sure our volunteers were supported through the intense experience of caring for struggling patients. So we directors just tried to do everything we could. We never knew enough, and relied on one another constantly. I became the person who knows about access to care; Julian understood ear, nose, and throat issues; Sarah was an expert in students’ needs; Dave handled clinic finances; our junior director Jacqueline was great at doing pap smears. Once the questions started rolling in, they never stopped until the last patient had been seen.
Sometimes, the last patient would get out the door at seven thirty, but sometimes it was at nine thirty. When the last notes were in and the volunteers were gone, we would lock up the computers, shut the safe, turn off all the lights, and walk out front across the basketball court, past the community garden, and down the cracked sidewalk to our cars. One director would have snagged the vials of blood from the lab to drop off at the UTMB emergency room.
I always liked that task. I would drive Box up to the emergency room and park next to the ambulances, then head inside. If the labs were only blood samples, I’d put them in the pneumatic tube in the ER to send them to the lab. But if there were pap smears or urine samples, I’d walk through the silent labyrinth of the nighttime hospital, passing from one building to the next.
I liked glancing down the hallways and through the open doors of rooms as I went. Sometimes there would be a bright-lit tableau, almost like a diorama: two young men at a bedside, each holding the hand of an elderly woman whose face was turned away. A woman in maroon scrubs pushing a giant X-ray machine down a hallway. Two doctors quietly writing. The nighttime hospital felt calm and peaceful after an evening at St. Vincent’s.
After dropping off the labs, I would drive back down the emergency room ramp and head to Arlan’s, the local grocery store, to get a beer. Everybody shops at Arlan’s, and a time or two I ran into patients whom I had just seen at the clinic. “Well, I reckon you need a beer, after all that,” one woman said to me.
“Yes, ma’am,” I said. Then I would go home and sit on the porch to have my beer. Sometimes my housemates would join me.
“Ah, your postclinic beer,” Natasha would say.
“Indeed,” I would say. “May they pry it from my cold, dead hands.”
From the porch, we could see UTMB just across the street. The campus hummed and buzzed and glowed all night, with the giant laboratories blowing steam into the night air. Sometimes I would look at the hospital tower and wonder why my St. Vincent’s patients couldn’t just be let in. And sometimes there would be a breeze blowing across the island from the Gulf, and I would just lean back and let the evening fall away from me.
CHAPTER 22
MALACHAI CAME TO GALVESTON FROM OUT OF STATE, AND he could not or would not explain how he got here. He walked into the clinic one day, told the student who saw him he was worried about a bump on his head, and asked to go off of his schizophrenia medication. Also, he asked for a testicle exam. He said there was nothing wrong with his testicles; he just wanted an exam. The bump on his head was a benign mole, and his schizophrenia, if he really had it, was well controlled. The student was a second-year, and she emerged from the encounter feeling thoroughly flustered. “Am I supposed to do a testicle exam?” she asked me.
“Um,” I said, “a testicle exam isn’t really indicated unless there’s something wrong. Pain, or a lump, or something. Let’s talk to an attending.”
So then the attending got involved, and he also could not piece together Malachai’s story, nor did he think a testicle exam was warranted. The encounter struck him as strange enough that he decided to Google Malachai, and what he found was so troubling that he came into the banana room saying, “We can’t see this patient. He can’t be seen by students. He needs to go somewhere else.”
I was in the banana room with Sarah, another director. Sarah looked up from her computer and pointed out the obvious: “I’m not sure that’s an option,” she said. “If he’s uninsured, there’s not really anywhere to send him.”
“No, this is serious,” the attending said. “This guy has a serious criminal record. I don’t think he should be here.”
“But, a lot of our patients have criminal records,” I said. I remembered what I had told a junior student just the week before:
Prison is just a place where they send poor people and black people. So if your patient has been in prison, you want to be alert for the possibility of posttraumatic stress disorder, because prison can cause it and because having it in the first place is a risk factor for going to prison. You should also think of certain infectious diseases that are prevalent among prisoners: tuberculosis, hepatitis C, HIV. You do not need to worry about what they supposedly did. If they’re here, they’re your patient.
Given the rate of incarceration of African Americans, a free clinic housed in a historically African American community center in Texas could not exactly be turning people awa
y because they had criminal records. It would be against the spirit of the House.
But the attending wouldn’t budge, and it seemed that the request for a testicle exam was the kicker, along with whatever the attending had discovered through his Google search. “This guy is obviously dangerous,” he said. “He could be on the lam. He should not be seen by students.”
Sarah’s face wrinkled up, and I felt my own eyebrows raise. We were not eager to tell any patient that they could not be seen here; to do so was, essentially, to say they would not get medical care at all. The situation was not fair, but it was very clear.
Sarah and I reached a compromise with the attending: we would reschedule Malachai for psychiatry night, so he could get his schizophrenia care in order, and make him “directors only.” Sarah and I would see him together (because the attending insisted that no woman see him alone).
So, Sarah and I went in to introduce ourselves. Malachai had a gentle demeanor; he nodded slowly along as we spoke and agreed to come back to the clinic on Thursday, for psychiatry night.
“Can I stop taking these pills now, please?” he asked.
“Keep taking them for now,” Sarah said. “Let’s not make any changes until you get a chance to meet with our psychiatry doctors.”
Malachai nodded, and we all shook hands. Sarah and I stood, but he remained sitting.
“Is there something else you need?” Sarah asked.
“Yes,” he said. “I would like to learn how to make more friends.”
“Oh,” Sarah said gently. “That’s a good thing to learn about. We’ll talk about that on Thursday.”
“Oh, okay,” he said. “Thank you.” Then he stood and we showed him to the front door.
The sign in the waiting room at St. Vincent’s says, ALL ARE WELCOME HERE. For a long time, I took pride in volunteering at a clinic where all patients were truly welcome. But eventually I realized that I, too, felt welcome here. It was my House. And so the fact that a volunteer doctor wanted to ban a patient because of his criminal record troubled me. I decided to take the issue to Mr. Jackson.
IF ASKED TO DESCRIBE HIMSELF, Mr. Michael Thomas Jackson will say that he is first a child of God, and then a male of the species, and then a man of African descent. He is also an Episcopal lay minister, and was the director of St. Vincent’s House during my years there. He takes the welcoming nature of St. Vincent’s very seriously. “You are not just welcome here. You are expected here,” he says. “The next person walking through that front door could be Christ Christself.” Mr. Jackson does not ascribe gender to the Lord.
Like me, Mr. Jackson also came through that door in his own unique way. He grew up in Washington, D.C., the son of a police officer and a CIA worker. His mother trained all her supervisors at the CIA but never got promoted; his father kept failing the D.C. sergeant’s test by a couple of points. Once upon a time his mother’s family was Roman Catholic in South Carolina, but then they were told they would have to sit in the balcony at church. Mr. Jackson’s grandmother said, “Well, that’s not going to work,” so they became Episcopalians. His mother’s family was eventually run out of South Carolina because the patriarch was organizing people for black voting rights, and so the family moved to the District.
Mr. Jackson started school in 1954, in the first year of desegregation. His first political activity was in ninth grade, and it involved lobbying Congress for better books in the public schools. (The D.C. school budget is controlled by Congress.) The racial mix of his schools changed with the times and with his family’s financial circumstance. He started out in a high school that was 60 percent black, but white flight happened so fast in the sixties that by the time he graduated it was 99 percent. He decided not to include a picture of himself when he applied to college, and he was accepted to Rutgers. His close circle of friends went to all the top colleges: Columbia, Penn, Harvard, Yale. It felt for a moment like things were changing.
But Rutgers was turbulent in 1968: classes got shut down for bomb scares, and the war was on. Mr. Jackson was not a formal member of the Black Panther Party, but many of his friends were, and the party was influential in leading him to a life of service. At that time, the Panthers were working to feed the people and running free medical clinics, but were also supporting armed revolution.* “I was a militant,” Mr. Jackson says, “for a time.”
But then, he says, love saved him. He fell in love with a woman, who introduced him to circles of people who were learning about nonviolence. He became convinced that armed revolution was not going to work in America. “Most of our models for revolution were taken from the developing world,” he says. “Ché was big. But armed revolt was not going to be the way this place was going to change. We couldn’t outgun the police or the military.”
Even so, Mr. Jackson does not believe that the Black Panthers were so violently repressed by the state because they were advocating armed revolution. Rather, it was because they built bridges with other communities: “The Panthers had to go because they were coalition builders,” he says. “They built coalitions with other communities. Malcolm had to go. Anytime you step out of segregation activities to unifying activities, you will be eliminated.”
Mr. Jackson committed himself to working to better the world, and to doing it as nonviolently as possible. He married in 1974, and then felt his first tugs toward the ministry. But it was not for a few more years, after separating from his then-wife and spending a year in Jamaica, that he was ready to tell the bishop that he could commit his life to Christ. And so it happened, though he did not finish divinity school. He was homeless for a minute, then became a lay minister. He wanted to be a prison chaplain, but he was called—literally called on the phone, by the bishop—to Galveston.
“I knew nothing about St. Vincent’s and I got lost every time I tried to get here,” he says. Galveston felt like being sent back to the hood. But they interviewed him at a restaurant on the seawall, and he’d always wanted to live near the ocean.
“I’m a radical heretic,” he tells me. “God is love.”
MR. JACKSON’S OFFICE is behind the reception area at St. Vincent’s House. When you walk into the House, you hit the waiting room first. The hallway to your right leads to the clinic, and the hallway to the left leads to the food bank, the chapel, and the offices. So on the morning I decided to track Mr. Jackson down to talk about Malachai, he was in his office fielding phone calls but he smiled and waved me in. I took a seat among the bookshelves and toys and sculptures, next to a giant stuffed banana with dreadlocks and a Jamaican-flag-colored hat, across the desk from Mr. Jackson. The nameplate on his desk said, “Servant in Chief.” He passed me a little metal brain teaser to play with while he finished on the phone.
“Rachel!” he said after hanging up, smiling broadly. “What brings you in here on this beautiful Monday when there is no clinic?”
“Hi, Mr. Jackson,” I said, smiling. “I wanted to talk with you about a patient.” And so I explained about Malachai: the request for a testicle exam, the Google search, the attending’s fear. How we figured out a way not to turn him away, but I was struggling with the notion that the student clinic might be out of step with the welcoming philosophy of the House.
Mr. Jackson listened and nodded. He already knew Malachai: he knew Malachai was working on his GED at the St. Vincent’s school, that he didn’t have family to rely on, that he was trading day labor for room and board at a safe house on the island.
“Listen, Rachel,” he said. “Every patient is a miracle. Malachai coming through that door at all—that was a miracle.”
“Well, yeah,” I said. “Okay. But then we shouldn’t be banning him!”
“He’s not banned,” he said. “He may not be able to work with that one doctor, but he’s still welcome here.”
“But what if he needs to see a regular internal medicine doctor?”
“Well, you may not be able to get him everything he needs,” Mr. Jackson said. And then he gave me a history lesson. He talked ab
out the years when the student-run clinic was just once a week, and never in the summers, how it expanded gradually. “I worked for years for us not to be a health home,” he said. He had envisioned the student-run clinic as a portal to care, where people would come to get triaged and then sent on to a higher level of consistent care. But the higher level fell through.
“You all,” he said, “can’t always give your patients everything they need. You can’t. But one is better than zero.”
“One is better than zero?” I asked.
“Sure. Okay. So you have this patient, and he comes in at zero: no doctor, no medications, nothing. And you want to get him up to five, don’t you?”
“Yes.”
“But you can’t get him to five, because five takes, say, an operating room. But you can get him to one. Even just coming through this door, that’s getting to one. And one is better than zero.”
Over the course of the year, I would have this conversation with Mr. Jackson many times. He always said that one is better than zero, and I always said that one is still an injustice when somebody needs five. We were both right. And eventually I learned that Mr. Jackson’s relative comfort with patients being at one rather than five was related to his belief that medical interventions are neither necessarily good nor essential to healing. For him, the heart of medical care is not in medications or surgeries: it is in one human being recognizing another human being, who is suffering. The heart of medicine is exactly the thing we do well at St. Vincent’s, even when we can’t do all the rest. Although he himself is insured, Mr. Jackson gets his annual physical at the student-run free clinic.
Over time, I have come closer to believing what Mr. Jackson believes. But I still argue that the trappings of medicine—the surgeries, the chemotherapy, the interventions—not only sometimes do fix what ails us but also are important symbols of the pledge that a person’s life matters. As technical and cold as medical interventions can be, they are often society’s best way of proving that a person’s life does matter.
No Apparent Distress Page 22