From a Week in Practice
Am Fam Physician. 2005 Feb 1;71(3):461-462.
The majority of medical problems can be handled on the mobile clinic. Today was an exception. JT, a family nurse practitioner, was staffing the mobile clinic with a third-year medical student, AW. The first patient was complaining of chest pain and had ST elevations in the precordial leads. An emergency medical technician (EMT) was called, and JT figured that it would be their only run for the evening. Several patients later, another middle-aged man came to the mobile clinic and did not even bother to sit down. He rested on the floor on his hands and knees complaining of severe abdominal pain. The “doubling over” sign is a good indication that someone is in severe distress. Again, after an assessment of the patient, an EMT was called. With some grumbling, the EMT transported the patient to the emergency department. The evening was not yet over when another patient showed up with a blood glucose level off the charts, blurred vision, and chest discomfort. JT assessed the problem and judged the patient was able to be taken to the emergency department in a taxicab. All three patients were admitted to the hospital, and JT and AW were glad when the day was done.
At 24 years of age, Maria was not ready for the news JOH had for her. Her symptoms were recent weight loss and “itchy feet,” but she denied blurred vision, urinary frequency, nocturia, or fatigue. The triage nurse checked her blood glucose level after listening to her story and family history. As a Latino who was moderately overweight and with both parents having had diabetes, Maria was at high risk for the disease. The blood glucose level of 459 confirmed the diagnosis. Her father, a heavy drinker, had ignored the warnings as the disease gradually robbed him of his sight, his kidneys, his limbs, and finally his life, all before reaching the age of 50. Maria's tears spoke volumes of the fear that now gripped her, yet also firmed in her a resolve to fight this disease. She was taking the first step: acceptance of her illness. The journey had just begun, yet JOH believed that Maria's journey would end in a better place than that of her father.
Michael's complaint was itching and peeling of his feet. However, when JOH asked him to take off his shoes and socks he demurred, “I've been sleeping in my car for three weeks and haven't really cleaned up.” JOH reassured him it would not be the first time he had experienced a pungent odor, often much worse than what Michael was worried about. A soft-spoken middle-aged man who had lost his job and his apartment, Michael was spending his first night in the homeless shelter. It took a lot of courage to make the step, yet the stress of being homeless had worn him down. Examination of his feet revealed tinea pedis and onychomycosis, but the pulses were strong and there were no open lesions. An antifungal cream would clear the tinea. JOH recommended a treatment for the onychomycosis that he came across in a journal with practical tips from family physicians—soaking the toes in diluted bleach (two capfuls of bleach in a gallon of water) for 10 minutes twice a day for two weeks. Though there is little clinical evidence to support its use, it was a practical and inexpensive approach to a common problem on the streets where simple cures are necessary.
A regular stop of the mobile clinic every week was the open shelter. For 20 years, it had been the largest men's shelter in Columbus. No one in need was ever turned away, which made it distinct among other homeless shelters in the area. Loss of funding from the shelter board had caused a gradual reduction in its services over the past several months. When the shelter had to reduce its number of staff, the men were only allowed to sleep there at night and were forced to be on the streets during the day. Efforts were made in the final month to locate housing for the 100 or so men who had called the shelter their home. Not everyone found a roof over his head, and many ended up back on the streets, or in camps in the woods or along the river. The mobile clinic moved three blocks west and set up shop at the Holy Family soup kitchen. Many of the “regulars” followed and continued to seek health care in the new location. But, many just disappeared. The turmoil has now quieted, the building housing the open shelter has been razed, and life goes on. But the problem of men and women without a home has not been solved.
Asouma's outlook on life had made 180-degree change from two weeks earlier when he was first seen by JOH. A homeless refugee from West Africa, he had witnessed the deaths of his parents and the rape of his sisters, and had his legs broken and face shattered by the rebels. He had come to the United States hoping for a better life, but had found no work, no home, and no friends. Someone had promised him housing but wanted a large amount of money up front. Asouma gave him the money but never again saw the money or the housing. While his teeth were hurting and he had been beaten outside the homeless shelter where he was staying, Asouma continued to hope. A selective serotonin reuptake inhibitor had been prescribed, and plans had been made for follow-up medical care and case management. Tonight, Asouma felt hopeful. He had begun work and had ongoing medical care. Asouma, in his halting English, said thank you, but it was the Outreach staff that felt even more thankful.
Most medical problems seen on the mobile clinic are not life-threatening. Patients often come for complaints that are annoying them or upsetting their daily routine. Because walking is such a vital necessity for everyone, many seek care for problems related to their feet. Ingrown toenails, onychomycosis, tinea pedis, corns, calluses, and blisters are seen daily on the mobile clinic. Amber was not homeless but had a job with low pay and no insurance. She got her meals at the soup kitchen, and when she saw the mobile clinic parked there, she requested treatment for her painful toenail. What JOH saw were two toenails shaped like ram's horns, thickened with fungus, and digging into the sides of Amber's toes. The family practice resident, NY, had never done an unguectomy but was willing to try. JOH excised the first nail after a digital block, and NY followed on the second. “I didn't feel the second one as much as the first,” Amber told NY. This of course brought a smile to NY's face, and he promptly relayed the message to JOH. The teacher always hopes his students will learn that quickly.
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 clinic. Dr. O'Handley continues to see private patients two mornings a week.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
Copyright © 2005 by the American Academy of Family Physicians.
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