Am Fam Physician. 2004 Jun 1;69(11):2585-2589.
“Doc, I really need help!” Tom was a huge man with hands like baseball mitts. This evening on the mobile clinic, he appeared desperate and had obviously been drinking. The triage nurses had been unable to get him to stop crying, the emotional floodgates having been opened by the power of ethanol. “I'm an alcoholic, and I have to quit or I'll do something I'll regret.” He was worried that he might hurt someone. When he reached the examination room on the mobile clinic, the tears were under control, but the plea to JOH to end the pain that was inside him was still there. The alcohol could provide some degree of analgesia, but he knew that it wouldn't last—with the dawn would come the terrible effects of alcohol withdrawal. That is what he feared most. “Is it all in my head?” JOH tried to explain that Tom's body was in a struggle with his mind and will. “It is up to you—it's your decision,” said JOH, but he realized the grip that alcohol had on Tom. Breaking away from its grasp was no longer in his power. A call to the emergency Engagement Center for urgent treatment was made, and Tom was transported into the black night like a minnow swallowed by a big fish. He had been given help. The question now was—would he accept it?
A young woman, Elisa, came to the mobile clinic complaining of foot pain of three weeks' duration. KR, the fourth-year medical student working with JOH this month, was unsure of the diagnosis. There was no heel tenderness, and the pain was worse at the end of the day, so plantar fasciitis was far down on the differential. There was some fluctuance to a spot in the arch of the foot that felt like a varicosity. Looking at the rest of her leg, it was easy to see varicose veins in abundance. The instep is not usually where one finds a varicosity, but that was the source of her discomfort. She was relieved to know that no bones were broken, but then had a “by the way” question about some lightheadedness. Conjunctivas were slightly pale, but JOH and KR were shocked when the hemoglobin level came back as 6.2 g per dL (62 g per L). Further history taking revealed extremely heavy menstrual periods and a history of anemia as a teenager. Chronic blood loss can sneak up slowly and relentlessly. It was lucky for Elisa that she had had foot pain, which brought her more serious problem to medical attention.
The history provided by the patient is like a vein of gold; it may not be visible at first, but chipping away at the dross reveals the true purity of the diagnosis. The patient standing before JOH with his arms held straight out to the side had an obvious furunculosis, which had started in both axillae and was now spreading to his trunk. Believing himself capable of curing his affliction with poultices and antiseptics, he had only delayed the inevitable visit to the doctor's office. But, how had this painful condition originated? He did not have diabetes and was not immunocompromised in any way. The clue lay in a poorly fitting life jacket that he had worn while snorkeling in the Bahamas one week earlier. The resultant chafing under the arms at first subsided, but then erupted with a vengeance into painful, red furuncles, depriving him of several nights' sleep. A potent cephalosporin would cure his misery. JOH hoped that the man's next life jacket would provide only safety from drowning—not a week of pain.
Laughter may not be thebest medicine, but a sense of humor is definitely a must for a physician. Without it, certain situations may become more problematic than necessary. Today, JOH was seeing a young Somali mother in the office for lower abdominal pain following a cesarean section. A new family nurse practitioner was beginning her first day with the practice and was being oriented on the job. After obtaining a urinalysis, which was negative, JOH returned to the examination room in which there was now a confluence of bodies. The office nurse was filling out information for the chart; the nurse practitioner was attempting to get more history from the patient, who spoke halting English; the Somali interpreter was praying in a corner of the examination room, making her salaams; and the medical student, JM, was observing the organized chaos in rapt silence. JOH sat down and made a quick assessment—he could chase everyone from the room or wait patiently for two minutes and enjoy the inherent absurdity of the situation. Needless to say, he chose the latter.
Family medicine is not the only subject learned by medical students when they choose an elective month with JOH, a fact JM discovered shortly into her rotation. Life on the streets is usually an eye opener for anyone coming from the sheltered existence of academia. One of the requirements of JM's elective in “Medicine for the Underserved” was spending time with one of the social workers who visits the homeless—not in the shelters, but in their camps under the bridges and in the woods. Besides seeing the living conditions firsthand, JM was given a brief didactic in the method that addicts use to obtain their drugs of choice. It was certainly a learning experience for her. This morning, before beginning the day of seeing patients on the mobile clinic, JM was able to observe such a proceeding firsthand from the vantage point of the driver's window. It is a sad commentary on our society that such activities go on in broad daylight, but it also testifies to one of the causes of homelessness itself.
Treating nicotine addicts is a constant battle. The damage done by cigarettes is so destructive that a good deal of a physician's time is spent countering the effects of this pervasive poison. The fact that patients fail to realize the health cost of inhaling tobacco smoke and its thousands of chemicals adds to the frustration that comes with dealing with this scourge. Some patients, however, are successful in breaking the habit and are deserving of the physician's sincerest encomiums. So, it was much less than exhilarating when JOH listened to the excuse of the patient who came to the mobile clinic complaining of shortness of breath. His two-pack-a-day habit was the ultimate cause of his present condition, and JOH tried to encourage him to quit—or at least cut back. “But Doc, I don't have the money to quit.” In other words, he lacked the funds to buy the patch or gum to “help” him quit. At that point, JOH felt reason had left the conversation, but he pressed on anyway, hoping for an opening. Finally, the patient acknowledged the need to cut back. It was not a victory, but a small step in the right direction.
Copyright © 2004 by the American Academy of Family Physicians.
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