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I felt my phone buzz in my pocket. It was a text from the intern. “We have an admission. I'll meet you in the emergency room.”

I never liked the emergency room, especially at my hospital. As a level I trauma center, it is always busy. Physicians and residents, EMTs, technicians, nurses, medical students, crash carts, and hallway stretchers pack the narrow passageways of the emergency room, itself a maze. I have trouble keeping my thoughts together over agitated patients' shouts and monitors' incessant beeping. But as I was learning, the most common way to get up to the floors was through the emergency room, so to the emergency room I went.

Our patient was writhing in a chair—a stretcher wasn't available. He was holding his abdomen, pleading for someone, anyone to help him. His name was Ajay*. He was in his late 30s, and, with one glance, I knew he was ill. I introduced myself. “I'm Olivia, a medical student. I'm from the medicine team upstairs.” Big, brown eyes stared back at me. I performed a quick initial survey: His hair was matted, and his clothing was stained with old sweat and dirt. Thickened, red nodules with necrotic cores rose from the surface of his arms.

I did my best to take a history, but his pain mattered more than my questions. He was homeless and struggling with opioid addiction, but his main concern was the left side of his chest. Ajay described a stabbing pain that worsened with inhalation; he winced when I gently touched the base of his rib cage. The intern joined me as I took a fragmented history, eyeing the patient's vitals—febrile to 101 °F, tachycardic—and searching for subtle signs of disease.

A chest x-ray ultimately revealed his left-sided pneumonia and rib fracture (Ajay later told us he fell). Blood cultures turned positive with a curious pathogen and, sadly, hepatitis C was teeming in his blood, with copy counts in the millions. For almost 2 weeks, I rounded on him. Every morning, I would listen to his heart for the gentle murmur of infective endocarditis and, thankfully, it never emerged. Over the course of a few days, his lungs started to clear, and my gentle pressing of his rib cage no longer caused him to flinch. We started to talk about other things. He told me he couldn't call his family for help—they'd be too disappointed in him. Ajay had previously worked at a Dunkin Donuts, but the throes of his addiction precluded him from maintaining a steady job. We talked about his addiction, and he agreed to start buprenorphine. We also discussed his new hepatitis C diagnosis; he wanted treatment, but he knew if he didn't have a place to stay, he'd be back on the streets, forgetting the small stint of sobriety he had while in our care.

After almost 2 weeks, his pneumonia was resolved, his blood cultures were clear, and his stay was at an end. Due to an issue with his social security number, he couldn't be discharged to an addiction facility so he'd have to go to the Board for Social Services first. Ajay was disheartened. He left with the numbers to our addiction medicine and infectious disease clinics and good wishes, which would likely prove useless in his harsh reality.

From time to time, I would peer into Ajay's chart in our electronic medical record. He had not contacted the infectious disease or addiction medicine clinics. He did not return to the emergency room. He was, as so many are, “lost to follow-up.”

—

Time marched on. With the end of May approaching, I found myself needing to buy a birthday present for my roommate. We have always given each other practical gifts: gas cards, gift certificates to our favorite restaurants, or candy for long nights of study. A Dunkin Donuts is conveniently located a short distance from our apartment, and I knew she'd appreciate some extra funds for caffeine. I tried entering the store, but the door was locked—the employee inside signaled for me to drive around. I got back into my car and pulled up to the drive-through window. The employee turned around, and big, brown eyes stared back at me.

Five seconds passed before we spoke to each other, our brains processing each other's faces.

The memories resurfaced. “Ajay?” I whispered.

“Yes, it's me! You took care of me!” He looked so well. His hair was no longer matted, and he wore his Dunkin Donuts attire with pride. He shared that he did in fact call his brother after he was discharged, and he helped him get his life together. He has been working for 5 months, has a place to stay, and is working on getting a car. I couldn't help but cry for him—how hard he must have worked to be where he is now. He asked me for my name. I gave him the same answer: “I'm Olivia, a medical student.” I asked him about the clinics. He lost the information, and he didn't know how to contact the hospital to make the appointments.

I smiled. “I can be a return customer tomorrow.”

*Names have been changed for anonymity.

Back to the September 2024 issue of ACP IMpact