How do we keep doing this?

Or believe the evidence of your eyes and ears.

One of my group chats was on fire this morning.

Someone had shared a link this story about a man getting put in a straitjacket and held for psychiatric evaluation at Ascension Macomb-Oakland Hospital because he claimed to be Alexander Morris, the lead singer of The Four Tops. The gag is . . . he was Alexander Morris, lead singer of The Four Tops, and he actually went into the hospital for chest pain.

We were tickled at the fact that no one on staff at this ER bothered to use google. We were grateful Mr. Morris did not die in that straitjacket from an undiagnosed, untreated heart attack while he waited on the psychiatric evaluation he did not need. We were exhausted at the shifting ways white supremacy continues to label Black folks as incompetent (first as unintelligent, then as mentally unwell) against all evidence to the contrary. It’s one thing to think a patient is lying about their identity, another to assume they are delusional. As far as I’m aware, neither of those things necessitates the use of restraint. And while I’ve seen lots of patients be physically or chemically restrained, I have never actually seen a straitjacket used in real life. What struck me is the way those biased assumptions are so baked into the fiber of the American healthcare system. Because having spent most of my waking hours in hospitals over the past 14 years, I can you that the staff likely convinced themselves that Mr. Morris was, in fact, amid a psychiatric break . . . even if he appeared perfectly lucid as he claimed to be, well, himself. I’ve seen it happen several times.

When I was a medical student, a woman walked into the ER with a laceration on her palm. She told the intake nurse she had been with a man she knew when he pulled a knife on her. They struggled, and she ended up with a bleeding gash on her hand. As we walked to her room, the resident told me it was important for us to get the full story. Who was this man? Why had she been hanging out with him late on a weekend night. Were there drugs involved? Was this a dispute over sex work? These sounded more like questions for the police to me, but what did I know? We briefly introduced ourselves and the resident launched into her line of questioning. The patient became increasingly irritated, and eventually decided she was just going to leave without treatment. I tried to intervene at that point to suggest she take a breath and give us a minute to regroup, but she was adamant. We moved on to the next patient and the resident offered an explanation about how important it was to make sure the patient had no drugs in her system so we could safely administer narcotics. We never got to examine the laceration. We never even offered her Tylenol, or Ibuprofen, or numbing gel. I couldn’t think of any street drugs could interact with those medications. I didn’t ask.

In residency I would get paged about patients (or their family members) who were reportedly being agitated or otherwise inappropriate, only to show up and find a person of color (often Black, but not always), who was mildly irritated because they had been waiting a long time or felt otherwise disrespected. And lately I have been thinking a lot about two pregnant patients, both Black, who I took care of as the attending (or supervising) doc on call.

I got a call one night to come to triage to help with a “labor rule-out”. Usually, my resident would do the initial assessment including a cervical exam and then call me with a plan: In early labor, stable, plan to discharge home. In early labor, may be transitioning, plan to have the patient ambulate and reassess in 2 hours. In active labor, or early labor but not stable for discharge, admit to the unit. Usually, I would come over and do my own assessment and decide if I agreed with the resident’s plan. If it was a senior resident calling, as was the case this evening, I very often agreed. But my senior resident was calling with no plan. The patient was obviously very intoxicated, and they needed my help. I hung up the phone and made my way over.

At the entrance to triage room 1, I ran into a labor nurse who started working on the unit before I even started med school, shaking her head, and muttering about how the patient was “so high”. I took a deep breath, stepped through the doorway, and quickly became confused. On a stretcher in the middle of the room was a Black woman, mid-to-late 30s, heavyset, very pregnant, writhing in pain. The monitor to her right showed that she was in the middle of a contraction. After about 45 seconds of hooting and hollering, the contraction eased, and the woman became completely calm. I stepped into a corner of the room as the experience nurse returned, still shaking her head, to draw labs. The resident came over to elaborate on our brief call: The patient was obviously high on something. It was impossible to get a history; they had tried to perform a cervical check, but the patient couldn’t relax. I watched the patient vocalize her way through a second contraction and then become completely calm . . . again. She appeared well. Her skin looked normal. When she spoke to her partner in between contractions, her speech was sensible. The monitor showed a completely normal fetal heart tracing - her baby’s heart rate (like hers) was neither too fast (cocaine might speed it up) nor too slow (narcotics might suppress it), the meandering line showed what we called moderate variability where illicit substances might either flatten it or make it jagged (marked, in clinical terms). Was the high in the room with us?

I introduced myself, acknowledged her pain, explained that it was helpful for our team to get a sense of how far long she was in labor and a sense of the baby’s size and position. She told me she had no medical or surgical history, no allergies, that these contractions were CRAZY. She was funny. So was her partner. Up close, her pupils were neither dilated nor constricted. Her skin was warm and dry. Once we were all laughing together, she agreed to another attempt at an exam. It was still hard for her, and to minimize her discomfort I did not insist on continuing until I got a complete sense of how dilated, how effaced, the baby’s exact position, but I got enough information to know she was in very early labor. Stable, but given her discomfort we could consider an admission for pain control. Outside the room the team had changed their tune. We’d gone from “She’s so high” to “She’s so fun!” and “I’d love to hang out with them in real life”. I considered asking them what had happened. How did a team of experienced nurses and a usually through, conscientious resident look at a woman in labor and conclude that she was intoxicated, despite all evidence to the contrary? I might have had the conversation, privately, with the resident. I chose not to pick that battle with the rest of the team at 2am.

The second patient came in during the daytime and she had already been seen by an attending. She was in triage, where a midwife was assigned during the day to evaluate patients. This woman was also in the hospital for a labor rule-out, but preterm. First, my colleague established how difficult this case had been for her. The patient wouldn’t give her a history - she just kept saying that she had noticed an odor from the vagina. She wouldn’t tell the midwife anything, and so she just kept repeating the various colorful ways the patient had described the vaginal odor. The only other bit of information she had to offer was that the patient had a flat effect. She was clearly high on something and so the decision had been made to order a urine drug test. The physician team needed to take over and decide if this patient was in preterm labor or not.

After rounds, I made my way over to triage 1, again. It was a busy evening, and the residents had a lot to do. Same room, same stretcher, same normal vital signs, same normal fetal heart tracing. The patient was alone this time, and she clearly did not want to be. I entered the room and leaned against the sink waiting for her to finish her phone call. She was speaking tersely into the receiver:

“Get here, now. You know what it’s like in these places. They either see that you have somewhere here to advocate for you or they don’t.”

After a few more minutes, she acknowledged my presence (“This lady keeps standing here like she doesn’t see me on the phone”) and hung up. I introduced myself and asked a few questions. She had noticed some vaginal discharge with a strong odor. She had not noticed contractions, although she had been told the monitor showed she was having some. She didn’t think her water was broken. She hoped not; she knew it was too early for this baby to come. She also agreed to an exam, and then to be admitted for preterm labor. We went over what to expect, and then I stepped out of the room. Sat down at a computer next to the midwife who had helped train me and was now my coworker and did not make eye contact as I said that I was cancelling the order for a urine drug screen — the patient was not high, she was scared. Maybe I should have asked what physical signs of intoxication she had noticed, or what made her suspect drug use beyond the patient’s “flat affect”.

Ascension Macomb-Oakland’s legal team has already issued a statement saying they do not condone racial discrimination. Almost every hospital I’ve spent significant time in since I started medical school has been a “safety-net” institution, full of staff and trainees who are there because of a stated commitment to caring for the underserved and fighting for social justice and health equity. I did not ask the ER resident why she acted that way because I was a medical student and I could not afford to piss anyone off. I didn’t ask the team how they saw signs of intoxication that did not exist because I knew what would happen – someone would be offended, someone would probably cry, someone would be unable to believe I was calling them a racist, didn’t I know they had dedicated their whole career to taking care of these patients? Someone would report the incident to their manager. If I was lucky, and the conversation didn’t just become about how I had made someone feel bad, maybe there would be an email about implicit biases or the danger of assumptions. More likely the email would be about the importance of presuming positive intent or how to communicate effectively in challenging situations. How do you get people not to see something that only exists in their heads? Black folks can be presumed high or insane for being in pain or afraid. How many people go to a hospital when they are not one of those things?