I’d been told in my hospital sign-out that Melanie was transgender, but I stumbled on the first day and referred to her as “he” in front of my medical team. “She!” she said immediately. “Oh, man,” I thought to myself. I was a hospitalist teaching medical students at one of the most liberal medical schools in the country — University of California, San Francisco. I should have known better.

When I took over her care from another hospitalist, Melanie had exhausted her options. After falling out of the window of her dialysis unit while trying to smoke during a dialysis session, she was banned from our county hospital. And, after multiple failed attempts to secure another dialysis center due to ongoing drug use and other behavioral issues, she was on the way to getting banned from our private hospital, too.

I steeled myself for a protracted battle. But when I started chatting with Melanie that first day, I was shocked to learn we had lived a few blocks apart in the French Quarter of New Orleans a decade ago. She had dressed as a man then, and I wondered if I’d seen her at the bar she worked at near my house. I was struck by the similarities between our trajectories — we had both lived in New Orleans until Katrina, then the Bay Area — and the sharp differences.

I was also struck by how funny and engaging she was. Reading her medical chart, I’d expected her to be withdrawn and argumentative. Instead, she was charming and easy to talk to. She asked me about my background and shared stories from hers. I’d ducked into her room for a five-minute assessment and somehow ended up talking for close to an hour. “Thanks for hanging out with me, doc,” she said as I walked out.

I talked to Melanie more over the next few days and started to realize how unstable her situation in San Francisco was. “If you discharge me from this hospital, I’m not going to make it,” she told me. “I’ll go out on the street and sell myself the first night, and then someone will kill me.” “San Francisco isn’t a safe place for me. I’m going to die if I stay here.”

That day in the case management meeting, I argued for getting Melanie back to Alabama. “She’s recently reconciled with her sister, and her sister’s calling the hospital room all the time. Melanie doesn’t have anyone in SF. Why are we trying so hard to keep her here? She doesn’t even have a dialysis chair!” “It’s a great idea,” one of the case managers answered, “But who on earth is going to accept this patient when we can’t even get her dialysis at our own hospital?!”

A week passed until our social worker triumphantly told me Melanie had a flight out the next day, December 23rd, from SFO. Not only that, but the city had heard about this case and decided to send a social worker on the plane with Melanie to escort her to Alabama. As excited as we were to reunite Melanie with her family, the city was even more excited to get her off its health care payroll.

I thought of Melanie many times over the next few months, especially since I was spending January through March in New Orleans with my family. I wondered how she was adjusting to life with her Alabama family and how they were handling her new gender identity. I hoped she was staying clean from drugs, as she’d promised me she would, and I hoped her new nephrologist was still OK with the arrangement.

I dialed Melanie’s sister’s number in June with some trepidation. “This is Dr. Glass,” I told her when she picked up, “I’m calling to check on Melanie Crawford.” “Oh, Dr. Glass, I’m sorry to tell you. My sister passed away about a month ago.” “What? Oh, my God. What happened?!” I asked in disbelief. Melanie’s sister went on to tell me that Melanie had thrived for many months. She had stayed drug-free, had been compliant with her dialysis schedule, had started to eat well and gain back weight, and she had even registered for classes at the local college. Our most optimistic plan, in other words, had magically materialized. “Well, what happened then?” I pressed on anxiously.

It turned out that after three or four months of marked recovery, Melanie had received a summons in Alabama for a court appearance in San Francisco.

Her family had protested since they didn’t have the money for transport and also feared that such a long trip back to a faraway place would be dangerous for Melanie’s health. The judicial system prevailed, however, and demanded Melanie return in whatever way possible.

Against her sister’s better judgment, Melanie borrowed money for a Greyhound ticket and set off for San Francisco. There was no way for her to get dialysis on the weeklong trip. Soon after arriving in San Francisco, she was found dead. “We don’t really know what happened,” said her sister, “but I swear they killed her by making her go back to San Francisco.”

My mind spun as I heard these details. I thought about Melanie headed home in the cab with tears in her eyes. I thought about her arriving in Alabama to be reunited with her old friends and family. I thought about her registering for classes and gaining weight, maybe even exercising and starting to have fun on the weekends.

And then, finally, I thought of this: “San Francisco isn’t a safe place for me. I’m going to die if I stay here.” In the end, it wasn’t the social worker, or the case manager, or a team of doctors who decided what would happen. It was exactly as Melanie had told us all along.

Marcia Glass is an internal medicine physician and author of Opiana.

Image credit: Shutterstock.com