"Give Me Your Tired, Your Poor / Your Huddled Masses"

A young woman with an extensive drug history relapses into her old ways. For a month, she takes escalating doses and combinations of different drugs: meth, heroin, ecstasy, cocaine, alcohol, tobacco, marijuana, prescription opiates, prescription benzodiazepines. It's a mess. She's brought in unconscious by a friend. Her physical exam shows evidence of track marks, recent falls, and poor self-care. Her labs show a large anion gap acidosis, but her lactate, glucose, and creatine kinase are close to normal. Her urine toxicology screen was "pan-positive," that is, had nearly every substance we tested. In the emergency department, she wakes up, flails her arms and legs so violently that she is sedated. Luckily, she protects her airway and continues breathing so she doesn't need intubation. But I am called to admit her (the emergency physician says, "I don't know what's going on, it's a mess, and she's critically ill, I need your help") and as I examine her, I think I could be in SFGH or Santa Clara Valley Medical Center. Our hospital, because of the nearby demographic, seldom sees this kind of patient: the poor, the trodden-upon, the marginalized.

Medically, the treatment for such conditions is mostly supportive. I tried to deduce what she was intoxicated with, what she was withdrawing from. There wasn't a single substance; it was not as if I could shine a light into her pupils and deduce what was happening to the soul within. But in time, her body metabolized its impurities and she emerged. Meanwhile, the anion gap acidosis which scared the emergency physician so much (she received several amps of bicarbonate in the ER) resolved surprisingly rapidly. My hypothesis was alcoholic or starvation ketosis (her ketones were elevated but the glucose was normal). Within just a day or two, she was ready to leave the intensive care unit.

I would love to report that when she woke up, we had a heart-to-heart, she renounced her ways, and I got her to a detox center, but such things never are. She was angry, mean, verbally abusive. But I reminded myself and our staff that this woman deserved as much as we could give. She reminded me of the last few lines on the Statue of Liberty:

"Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!"

Many of us physicians enter medicine with such golden ideals, warm hearts, and open arms. We scatter into private practice and posh jobs, and a veil falls between us and that which inspired us. From time to time, I reminded of this, how in becoming a doctor, I was drawn to these patients, who need our care, our love, our attention.

The title of his post and the image represent the sonnet "The New Colossus" by Emma Lazarus, which is inscribed inside the pedestal of the Statue of Liberty. The image is in the public domain, from Wikipedia.