Diary from a Week in Practice

Am Fam Physician. 2002 Oct 1;66(7):1200-1202.

Monday

The painful lesion on his foot brought a homeless man to the mobile clinic. After walking 55 miles from Columbus to Dayton one week earlier, the patient naturally developed sore feet. But the pain was now barely tolerable. The skin over the ball of the foot was callused and thickened, and in the middle was a pale area that was 5 mm in diameter. The family practice resident initially assessed it as a plantar wart that had been inflamed by the trek. When JOH evaluated it, the tenderness seemed out of proportion to the pain that would be expected with a plantar wart. The patient was told that it was possibly a small abscess that would need to be drained, but JOH was not sure what he would find. Freezing the area with ethyl fluoride and aspirating with a syringe and needle yielded no fluid. But using a #11 blade to open the area further produced the pus that was causing the pain. The patient was much relieved and was able to navigate the streets of Columbus again, but any return trips to Dayton would not be done on foot.

Tuesday

A frequent visitor returned to the mobile clinic this evening with a self-inflicted 4-in gash on his left forearm. The innumerable scars on his arms attested to the emotional turmoil that the patient had been going through on a daily basis. The slice had been made after the patient “lost” his medication during a fist fight, which led to an uncontrolled emotional outburst. As MH, the family nurse practitioner, cleaned and sutured the wound, the patient punctuated the air with Henny Youngman-type one-liners. These were not so much amusing as sad, and they served as a commentary on the patient's fragile psyche. What leads people to harm themselves? Are they starving for attention, for the recognition that they are real? Are they self-hating people who assuage their guilt by bringing pain to their bodies? Are they directed by inner demons that not even they understand? Whatever the reasons, it is sometimes difficult to feel empathy for their plight. As he was leaving, the patient said that he would not do such a thing again. Looking him directly in the eye, JOH wanted to believe him. His gut feeling told him otherwise.

Wednesday

Returning from lunch at the hospital, JOH encountered an Hispanic woman whom he had seen on the mobile clinic a few weeks earlier. She had had pelvic pain for months and was scheduled for a pelvic ultrasound that day. The puzzled look on her face spoke volumes about the difficulty that she and her husband were having locating the ultrasound testing area. For 30 minutes they had been trying to find the location without success. There were no directions on the appointment sheet, and neither she nor her husband spoke English. It was pure serendipity that JOH found them. The hospital has many different wings, and even he had to ask for help with directions through the various floors and hallways. When they finally reached the proper area, an interpreter was waiting and took over for JOH. Today, the reality concerning the difficulties of navigating through our health system was brought home to JOH. For patients who do not speak or understand the native tongue, the problems are multiplied tenfold.

Thursday

A pleasant, middle-aged woman came to the mobile clinic along with her 10-year-old son. Both had symptoms of gastroenteritis, but the mother's story of recovery from a disabling mental illness was the most intriguing part of the visit. Skepticism had been the response from her psychiatrist when she related the complete change in her way of thinking and in her attitude. Her diagnosis of bipolar/schizoaffective disorder had been disabling for years, and she had been dependent on a variety of major tranquilizers. She was now functioning normally without medication. JOH was curious about the change and asked what had led to her recovery. She related matter-of-factly that her thought processes normalized and her healing began when she let go of the anger and hatred for her parents that she had been holding onto since childhood. When she was able to forgive them for the pain she had experienced while growing up, from beatings both physical and verbal beatings, her mind began functioning normally again. It was a heartwarming testimony. She attributed a good deal of the change to the effect that her son had on her life. He was able to convey to his mother the destructive track she was on and helped her realize the person she wanted to be—and indeed the person she now had become.

Friday

Patients can often figure out ingenious ways to treat themselves when necessity forces their hand. JOH encountered a young woman today who has devised a treatment for acute shortness of breath. Her problem had been present for years and was brought on by hot weather, especially at night while lying flat. Activity in hot weather also seemed to precipitate the difficulty in breathing. She noticed wheezing at times and there was a family history of asthma. When JOH asked what she had been doing to make it better, she smiled sheepishly and asked, “Do you really want to know?” She had learned that when she feels as if she cannot draw another breath, she asks her boyfriend to blow forcefully into her mouth while holding her nose. This would “open her up” and provide several hours of relief. This was the first time that JOH had heard of rescue breathing used for asthma. He provided the patient with a beta-agonist multidose inhaler for times when her boyfriend might not be available.

Saturday/Sunday

JOH saw a miracle today. It did not actually happen today, but occurred over the past several months. A wasted, emaciated patient seen previously, who five months earlier could not even come aboard the mobile clinic under his own power or talk about his problems, showed up 30 lb heavier, lucid, clean-shaven, and motivated. He had been sent to a nursing home in a terminal state, but instead, under their solicitous care, was now thinking clearly and looking stronger and fitter than ever. In hospital intensive care units, physicians see these miracles every day, but when it occurs in a homeless man who has abused himself for years with illicit substances, it is awe-inspiring. The patient has not yet graduated from the street, and he might still fall back into old habits. But even he acknowledged the visible change that had taken place. JOH hopes and prays that the inner transformation will match that which has occurred on the outside.

After years spent in private family practice and academia, John O'Handley, M.D., is medical director of the Mount Carmel Outreach Program in Columbus, Ohio. The program provides free medical care to uninsured and homeless patients throughout the city on a mobile coach. Dr. O'Handley continues to see private patients two mornings a week.

Address correspondence to John O'Handley, M.D., 1335 Dublin Rd., Suite 110E, Columbus, OH 43215 (e-mail: johandley@mchs.com). Reprints are not available from the author.

In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.


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