Diary from a Week in Practice
Am Fam Physician. 2003 Feb 1;67(3):502-504.
The second-year medical student had taken a meticulous history from a 30-year-old man whose chief complaint was headache. When JOH came into the mobile clinic's examination room, however, the story changed. What started out sounding almost like temporal arteritis turned into a burning feeling in the chest, accompanied by water brash. It was not the fault of the medical student, who had never taken a history from a patient with schizophrenia. The task was made even more difficult by the patient's habitual drug abuse. The patient liked his cocaine and the feeling it gave him, and he was not interested in abstaining from it. At $3.00 a hit, he could still afford the drug that would eventually destroy him. However, his symptoms of gastroesophageal reflux disease were what brought him to the mobile clinic, and that was something JOH could treat. He could also explain the consequences of cocaine on the body. Would this change the patient's behavior? Would he be able to live with the pain of a catastrophic mental illness without the hour's respite afforded by the illicit substance? JOH could only give an educated guess at the answers. He was not optimistic.
Listening to a homeless person's stories and gaining insight into where he or she has come from can provide a whole new perspective on that individual. The clinic work was finished earlier today than usual; JOH was walking toward his car when he saw one of his favorite people. Today, for some reason, the man just wanted to talk. He called himself a hustler, and he lived on the streets using his wits and powerful frame to keep him out of too much trouble. He slept wherever he could find a bed, never knowing from one night to the next where that would be. His grandmother had died recently and left him several acres of farmland. But, “I had no use for it,” he said, and he signed it over to his nephew. “He'll go to college and do well. I don't need it.” Such detachment from earthly possessions would be hard to find in a canonized saint. “Say a prayer for me,” he said. JOH smiled and shook his hand. He was grateful to have shared a little more of this man's life. Change comes slowly for most. JOH would continue to pray.
The clinic was officially closed, but there were six more patients to see. For the most part, they had simple problems, except for Martin. Homeless for years, he lived under a bridge when the weather was above freezing and in a shelter when it dipped below that. Martin was a diabetic with paranoid schizophrenia, and he had been out of his insulin for over a month. He had been tried on an oral hypoglycemic, but his voices had only become worse with that regimen. When he was alone, the voices told him to kill himself; when he was with others, the voices targeted them. He described the voices as “screaming, coming at me from all directions.” Martin had stopped the medications that controlled the voices, the valproic acid (Depakene) and risperidone (Risperdal), for reasons only he knew. Now he wanted to resume his insulin “because it may help control the voices.” JOH was glad that he was willing to restart the insulin, even if it was for the wrong reason. Perhaps with his glucose under tighter control, the other issues could be addressed as well. Any glimmer of hope in a life decimated by severe illness should be viewed as a victory.
It is difficult having a chronic disease, and each person responds differently to this challenge. The last patient of the day today had diabetes, with a blood sugar level of 423 mg per dL, and he was in a wheelchair. The triage nurses had kept him in the shelter, and JOH and a medical student left the mobile clinic to assess his problems. Attitude seemed to be the most serious one. He was being followed at the Veterans Affairs Hospital for a foot ulcer, but now he was unwilling to take his insulin because he had no food. The nurses brought him food, but he had refused to eat it because it included cheese. “It'll clog my arteries, and I don't want to be a statistic like my parents.” The patient had a medical appointment the next day, but no money to make the telephone call to access the taxicab. The staff assured him that he would have access to the telephone in the morning, and one of the nurses even gave him money for a pay telephone as well. His litany of complaints did not end there, however, but continued until the medical personnel decided that “enough was enough.” There is only so much that can be done for other people. The time comes for everyone to hear: “The ball is in your court. Run with it, or seek assistance elsewhere.”
As a general rule, schedule II medications are not dispensed or prescribed on the mobile clinic. This discourages those patients with drug-seeking tendencies and provides for emergencies requiring that level of medication to be routed to the appropriate facility. However, some patients do not fall into either category. Today, JOH saw a former graduate student at a prestigious university who had been working toward a Ph.D. in religion. She was now living in a shelter, and she had come to the mobile clinic with a chief complaint of fatigue. JOH became suspicious when she said that her former physician had prescribed dextroamphetamine for the problem after evaluating other causes. In listening to her story though, JOH realized that narcolepsy could be the underlying problem that had scuttled her academic career and was now threatening her job as a receptionist. Despite 10 hours of sleep per night, she fell asleep at work. Her honesty, attitude, demeanor, and words were not those of a patient seeking controlled substances. JOH attempted to connect her with a neurologist, but she was reluctant to pursue this path because of finances and a fear that her employer would learn of her illness. JOH reassured her that this would be the best option. The patient was in a distressing situation, but with further evaluation the correct diagnosis could be determined, and her life would take a turn for the better.
As physicians, we are taught that someone with a plan to commit suicide is a psychiatric emergency. The thin, bearded, middle-aged homeless man came to the mobile clinic because of cold symptoms. But he admitted to the triage nurse and to JOH that he was depressed. When asked if he had suicidal thoughts, he hemmed and hawed, and eventually denied having thought of a specific plan. But what was denied explicitly was acknowledged implicitly. He had stopped taking his medication for human immunodeficiency virus infection, choosing to let the disease run its course; he continued to smoke 40 “rolled” cigarettes a day, despite a spot on his lung found five months earlier on a chest x-ray, and a weight loss of 20 lb; and he continued his binge drinking, despite having a liver that was four finger-breadths below the right costal margin and being told by another physician that his liver was “mush.” Technically, he was carrying out his own destruction. When put in that context, he acknowledged the truth. JOH hoped and prayed that the truth would help to heal his desperate condition.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
Copyright © 2003 by the American Academy of Family Physicians.
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