Community Critical Care

It's been interesting seeing the span of patients admitted to the intensive care unit at a county hospital as opposed to a tertiary academic medical center. While some cases - the older nursing home patient arriving with septic shock from a urinary tract infection, the severe pneumonia requiring an artificial breathing tube - are the same, many are quite different. I've seen more patients with diabetic ketoacidosis here in a few weeks than I have the past ten months. I've seen more methamphetamine use, more intentional overdoses, more end stage cancer. The microcosm of a hospital's patients is simply a reflection of the community. Here, we see patients who cannot fill their prescriptions. They run out of insulin. They run out of food. They have nowhere to sleep. They have no family, no friends. We see patients who are plagued with voices. They are victims of domestic violence, victims of abuse. They are addicted to street drugs and no matter how much they want to quit, cannot escape an environment that has no exits. Our patients have criminal histories, altercations with police, restraining orders. They have no identity, come in unconscious, and push our social worker's finesse. We've identified patients based on bank account numbers from scraps of paper in their pocket. We've identified patients by asking the sheriff's office to fingerprint them. Our patients don't have regular doctors. They are immigrants, they are migrants, they are uneducated, they are poor, they are minorities. They are the ones we hope to help with universal health care. They are the ones who are at the most need for care, at the fringes of society, the vulnerable and the sick. They physicians who work here gravitate towards caring for these in need, and I am awed to see their dedication and passion.

Medicine and disease are intensely social phenomena. We in the ivory tower like to forget this. We think it is about advanced diagnostics, minimally invasive procedures, targeted therapies, personalized medicine. But, in the real world, it is more about where you live, whether you feel safe, your education, your financial security, your job, your vices, your psychiatric diseases. We see so many patients who are here for their fifth, sixth, tenth time of diabetic ketoacidosis. Some leave once they feel better against medical advice, and I wager we will see them again when they neglect to take their insulin, fall to using drugs. Others I hope we can salvage; one man has nowhere to store his insulin, which must be refrigerated. We hope our social worker can place him in a board-and-care that can maintain his medications. Another immigrant who has never seen a doctor in the U.S. begins to understand his diagnosis of diabetes, and we connect him to a primary care physician who speaks his language. The safety net we throw is not just medical stabilization, it is milieu of all the other things that matter more to the patient and matter more to his health. It shines a light on why it is so challenging to improve health outcomes outside the sterile lab. There are too many factors, too many variables that we cannot control.

At Stanford, I will learn to care for those tertiary center referrals, the bone marrow transplants, the rare malignancies, the enriched population of complex medical problems. But I am slowly beginning to understand how to care for the man who walks in off the street, whose medical problems are far simpler than his psychosocial circumstances.