Diary from a Week in Practice
Am Fam Physician. 2003 Aug 1;68(3):457-458.
The personnel devoting their time to homeless patients are a godsend. This evening, one patient posed a difficult dilemma. The history reflected a hand injury one month earlier, involving several extensor tendons. After receiving primary closure of the wound in the emergency room, the patient had planned to follow up with a hand surgeon in 10 to 14 days for secondary tendon repair. According to the patient, he had been given “the runaround” when calling the surgeon's office and was unable to get an appointment. Indignation rose in JOH as he listened. Weren't the hospital and physician who was on-call legally responsible for the care of this man, even though he was indigent? The longer JOH pondered the proper steps to take to repair the tendons, the clearer the picture became of what took place. A perceptive nurse who questioned the patient further learned that he had actually been offered the opportunity for primary tendon repair under regional anesthesia at the time of his initial presentation. He refused because he wanted to be “put to sleep” instead. He was then offered a referral two to three days later for secondary tendon repair. The problem of disposition was still not solved, but the picture of the events was in sharper focus. The proper steps could now be taken for “closure.”
A middle-aged Latino man experienced a stinging sensation in the dorsal proximal aspect of his right forearm attributed two months earlier to a bee sting. But, whatever it had been had now migrated to the volar surface of the forearm. Given his cultural familiarity with organisms that migrate, the patient believed it was caused by parasitos (parasites). JOH examined the arm and could feel and see the source of the patient's concern. A superficial foreign body proved to be metallic on fluoroscopy, and JOH told the resident physician, SK, that he had a surgical procedure for him. The extraction was done under local anesthesia with a no. 15 blade and hemostat. A 4-cm piece of wire was found, and the patient was grateful. Although it was an inanimate object, it had migrated. But, it was still not quite a parasito.
Teasing out ailments of a psychogenic origin from those caused by other pathology can be difficult. When there are language and cultural obstacles in the way, the work is even more arduous. The 30-something, Somali woman had multiple complaints—breast tenderness, fatigue, constipation, abdominal pain, and headaches, to name a few. JOH asked about sleep patterns—“not good”—crying spells—“I can't cry”—ability to enjoy things—“no.” The picture was becoming clearer. How could she be happy with her family in Somalia still suffering the vagaries of civil strife? But, she clearly had an inner strength and stability that were evident in her voice and manner. She would eventually be healed, not from this visit, but because of the support of those who cared about her—the translator, the nurses, the outreach case managers, and the community. It would start today, but it would not end here.
The triage nurses inside the homeless shelter had already initiated a referral form for a surgery consultation prior to sending the young man to the mobile clinic. Two years earlier, he had accidentally shot himself in the right hip area with a .22-caliber pistol. The wound had never been attended to by a physician, and it was now becoming more tender and bothersome. JOH examined the area, which was raised, tender, and 3 cm in diameter. It could not be evaluated by fluoroscopy, but it appeared accessible to a minor surgical procedure. The patient was taken aback—he was not expecting to be offered this particular treatment—but agreed to have it done after he had a cigarette to “calm his nerves.” As he exited the mobile clinic, JOH was not convinced that the patient would return, but went ahead with preparations for the procedure. Within five minutes, the patient did return, signed the consent form, and laid on the examination table in preparation for the excision. After local anesthesia was administered, the area was opened, and approximately 5 mL of pus was drained. At the base of the cavity, a dark metallic object was grasped and pulled out with Adson forceps. It was indeed a .22-caliber bullet. The somewhat tarnished bullet was then returned to the relieved patient in a plastic bag, where it would cause no more harm.
The weather was sunny and balmy. The elderly patient was brought by two social workers to the homeless shelter from his camp in the woods. According to the social workers, the problem was the presence of multiple ulcers on the patient's feet and toes, thought to be caused by frostbite. For several days, they had been trying to persuade the man to be seen by a physician and had finally been successful. What JOH saw when the shoes and socks were removed was not good, but it was not quite as terrible as he had been led to believe. The multiple ulcers looked reasonably free from infection. The onychogryphosis was striking, but quickly dispatched with a pair of trusty nail clippers. After dead tissue had been debrided from the toes, the ulcers were cleaned and dressed. The patient denied any chronic diseases, except a vision problem that was evidenced by the advanced corneal cataract in one eye. But, the answer to the ulcers was discovered after administering a blood glucose test, which came back in the high 400s—diabetic neuropathy! The social workers were to be commended for their determination in bringing the man in for medical care. A beautiful day ended on a high note.
Listening to the patients is not just a good thing to do; it is the primary, quintessential obligation of the physician. An elderly man came to JOH's office today because “my wife told me to come.” The concern had been some pain in his back following a minor injury in the kitchen. As it turned out, he was not worried about that at all, but rather was concerned about his lack of energy. JOH glanced at a complete blood count (CBC) that had been done several months earlier, and saw a hemoglobin level at the lower limits of normal. “Try a multivitamin with iron, and recheck the CBC in six to eight weeks” was JOH's knee-jerk response. The patient was unconvinced, and he suggested the possibility of getting a vitamin B12 shot. JOH's first thought was to dismiss this option; he felt this treatment was a panacea long used more for its placebo benefit than for its physiologic necessity. But, he caught himself, redirected his attention to the CBC, and noticed the markedly macrocytic indices that he had missed on his earlier perusal. Apologizing for his hasty suggestion, JOH explained that a closer look at the patient's blood might provide a more accu rate diagnosis. Additional blood tests were ordered, and it is hoped that a more energized patient will eventually emerge from an encounter that could have been fruitless.
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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