From a Week in Practice
Am Fam Physician. 2005 Jun 1;71(11):2085-2086.
The holidays are supposed to be happy times with family and friends. Peter was returning to the mobile clinic for replenishment of his asthma medications and because of a history of red, matted eyes. He had been to a neighborhood health center, but they had to send away for his medications through the Patient Assistance Program, which could take four to six weeks, and he was in immediate need. A long-time resident of the shelter, Peter had a job for almost a year, but then fell back into the pattern of homelessness, which is difficult to break. I asked how his family was and a look of despondency crossed his face. His mother had visited Columbus, Ohio, from Dayton, to ask Peter to come home for the holidays. However, he was reluctant to leave the city that he knew, even with the enticement of a home-cooked meal. The saddest part of his story was not seeing his brother, who had been incarcerated for 15 years on a sentence of life without parole. He had come up against the Three Strikes and You’re Out rule, and the separation from his family was leading the brother into a severe depression. Peter’s mother had taken her son’s case as far as the Supreme Court to attempt to mitigate the sentence, but had been denied a hearing. There is nothing stronger than a mother’s love, but there is also nothing sadder than a family torn apart by mistakes made in the brashness of youth.
The victims of disasters are not only those who lose their lives or their loved ones. For the ones who continue enduring the trauma through which they survived, life can be more than they can handle. Richard, in his 50s, came to the mobile clinic today with a severe case of cystic acne. “It’s from stress,” he stated. When his story unfolded, I didn’t doubt him. Twenty years earlier, the death of Richard’s only son and his subsequent divorce, had resulted in a similar outbreak. He kept going, though. A successful financial analyst in New York, he had survived September 11 while working in one of the towers of the World Trade Center. The trauma of that day had led to depression, and he ultimately had to quit his job, leave the city, and stay with friends in the Midwest. Now, his savings were gone, and he was without family and resources, relying on the generosity of friends. A deep faith had kept him going, but at this low point he freely admitted that he would have preferred to have died that day. His face spoke volumes about his struggles, not only from the physical disfigurement of the acne, but also from his expression and tears that were flowing so freely.
Today was devoted to health screening of political refugees. Bantus from Somalia, families from East Africa, people escaping civil war and resettlement camps in Kenya, all are welcomed to enjoy the freedom offered by America. The experience can be overwhelming: from the 36- to 48-hour trip to this country, to assimilating into a different culture. Diseases that Americans encounter much less frequently must be screened for—tuberculosis, malaria, parasitic diseases, and hepatitis. The majority of refugees are in excellent health; an active lifestyle and sparse diet have spared them many of the ravages that come with abundance—hypertension, diabetes, osteoarthritis, hyperlipidemia, and coronary artery disease. Families with four to eight children are normal. The wide eyes of the toddlers attest to the wonder of experiencing never-before-seen sights. J.K., who drives the mobile clinic, also has become an expert phlebotomist. The young mothers hold their infants and try to distract them from the ensuing needle stick with cries of “bess bess” (it’s almost over) to reassure the little ones that their pain will not last. Medical screening is but a small part of the effort that must be made to resettle the refugees. Social services are even more important in providing a support system for people coming from countries where strife is the norm and deprivation an everyday occurrence.
Substance abusers are trusting souls. They trust their lives to dealers who tell them a drug is pure; they trust those they share needles with when they tell them they are free of human immunodeficiency virus or hepatitis; and they trust some unknown power that will protect them during the vulnerability of a drug-induced coma. A few survive unscathed after abusing their bodies and minds for years. Tommy came to the mobile clinic because of a flare up of asthma. A 25-year addiction to crystal methamphetamine had not seemed to rob him of his faculties, and he had been clean for two years now. He had not yet climbed out of the prison that the streets build around the homeless. Years of foraging for food in dumpsters, of taking low-paying jobs to support his habit and its subsequent high, had not destroyed his reason or sense of humor. He described in detail the rush, racing heartbeat, and sweating that accompanied his habit. I had to wonder how the effects of crystal methamphetamine could be enjoyed when so many patients come to the doctor to find a remedy for such symptoms. An addiction is not something that can be rationalized. Tommy was thankful for where he was now and smart enough to know he did not wish to return to the pit from which he had fought his way out.
Although many use the mobile clinic as a medical home, it does not purport to have that designation. It was with some surprise that I encountered Ignacio, who came to the clinic for the first time. He had been to several emergency departments and several specialists for testicular pain and swelling over the preceding four months. According to Ignacio, the physicians had tried to assure him that there was nothing seriously wrong. Although the problem had been worsening over that time, neither a definitive diagnosis nor treatment had been offered. What I saw on examining Ignacio was a testicle that was three times the normal size, tender, did not transilluminate, and was associated with enlarged groin lymph nodes. I decided to refer Ignacio back to the physician who had seen him originally with a copy of his progress notes, which indicated my concern about testicular cancer. Perhaps this would get the attention of the specialist who may not have seen Ignacio in the state in which he was now. An ultrasound had been done previously and this had not raised an alarm with the previous physicians. A change in presenting signs and symptoms can occur over time and this was probably one of those times.
The entrance wound of the bullet was just above the right acromion process, but there was no exit wound. Instead, a small, moveable but firm mass was palpable over the right mid-clavicle. Brandon had been shot on the street four days earlier and went to a local emergency department for care. His entrance wound was cleaned and dressed, but for some reason the physician did not want to remove the 22-caliber bullet fragment even though an x-ray had confirmed that it had lodged over his clavicle. If a bullet is within a joint, it usually is removed to prevent structural damage by a foreign body such as impingement, pain, or functional limitation. When a bullet is within the soft tissue and not causing problems, its removal is a decision made between the patient and the physician. When Brandon arrived at the mobile clinic, he was insistent about having the bullet removed and J.T., our nurse practitioner, was eager to perform the excision. After signing the consent form and seeing the equipment in the exam room, Brandon had second thoughts, especially when he caught sight of the needle for local anesthesia. “Can I smoke a cigarette and think about it?” he queried. J.T. did not want to do anything that the patient might regret and told him to go ahead. She was not sure if he would return. He did, bringing with him a friend for moral support, and allowed J.T. to proceed with the surgery. Brandon wanted the bullet for himself, and J.T. happily complied with his request. The procedure went smoothly, the patient was happy he had not given in to his initial fears, and he also was provided ballistic evidence against his assailant.
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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