Diary from a Week in Practice
Am Fam Physician. 2002 Apr 1;65(7):1313-1314.
“We need a doctor for an emergency right away!” The message came over the two-way radio from a triage nurse inside the shelter to personnel on the mobile clinic. JOH envisioned several scenarios as he hurried to the shelter. “Was a nurse in danger?” “Was a patient seizing?” “Was someone acting out delusions?” When he reached the area where the nurses had directed him, JOH saw a man leaning on a table with his head on his hands. Pulse and respiration were intact, but the man was unresponsive to questioning and looked puzzled. Fearing a stroke or transient is chemic attack with expressive aphasia, JOH requested that an ambulance be called.
By the time the paramedics arrived, the patient was alert, responsive, and adamant about not being transported to the emergency department. A previous episode was related where the patient removed his clothing and threatened staff members with a board. Today, the man appeared not to be a danger to himself or others, and he refused further treatment. JOH returned to the mobile clinic to continue seeing patients.
The man was in obvious pain as he stumbled onto the mobile clinic and then walked slowly into the examination room. The resident quickly and appropriately assessed the situation. Marked upper abdominal tenderness, absence of bowel sounds on physical examination, a history of vomiting all food and drink, and failure to pass stool or flatus for several days indicated a primary diagnosis of small bowel obstruction. JOH asked the resident if she knew one of his favorite mnemonics—HANG IV—H = hernia; A= adhesions; N = neoplasm; G = gallstone ileus; = intussusception; and V = volvulus. The resident had not heard that particular mnemonic before, but she quickly added it to her peripheral brain—her personal digital assistant. JOH has been using the mnemonic for years after learning it from a general surgeon when JOH had failed to diagnose an incarcerated femoral hernia in an elderly female patient.
The cause of this patient's pain could not be determined on the mobile clinic today, but JOH was hopeful that it would be in the emergency department where the patient had been quickly dispatched.
JOH's Spanish still needs work so, when seeing Hispanic patients, he relies on translators. Translation can sometimes be problematic even with excellent medical translators because of the additional time required to communicate and the occasional meaning change that occurs from one tongue to another. A young woman presented with straightforward respiratory symptoms and a missed menstrual period, After a history and physical examination, JOH stepped out of the room to obtain the pregnancy test results. When he returned to the examination room, the translator, with the patient's permission, related that the patient's boyfriend had been physically abusive because she had not provided him with a child. The patient also indicated that she was depressed and unsure about what to do about her situation. She was referred to a gynecology clinic and to Social Services.
It seems that the presence of the translator, a gentle older woman, led to the patient offering this crucial information. JOH gained heightened regard for the work performed by these important intermediaries, and felt that, because of them, he was able to provide more meaningful medical care to patients.
It is always heartening to have a patient return with a story of a cure. A woman who had been treated for reflex sympathetic dystrophy (complex regional pain syndrome 1) returned to the mobile clinic today to see JOH. She expressed deep appreciation for the medical care she had received, but it was actually her compliance with the recommendations that played the greatest role in her recovery. This is not always the case with patients living in shelters or on the streets. Too often, JOH hears laments like “my pills were stolen,” or “lost my medicine before it was finished.” The burden is placed on patients to comply with medical instructions and follow up with the appropriate physician. Even when a ride to an appropriate medical facility is provided by an outreach program, the patient still has to be at the proper place at the proper time to take advantage of the transportation opportunity.
Understanding the many challenges for these patients makes a success story like the one JOH heard today doubly rewarding.
As the medical student presented the patient, JOH felt a sense of déjà vu. A painful forefoot that made walking difficult brought to mind a similar case of cellulitis he had seen only two days earlier. There was definite swelling of the right forefoot along with calor, dolor, and rubor. The mechanism in both cases was untreated tinea pedis that resulted in breaks in the interdigital skin and passage of bacteria into the lymphatics. The treatment consisted of broad-spectrum antibiotics, pain medication, and, of course, antifungal cream for the tinea. JOH has learned that when patients develop lower extremity cellulitis, it is always important to look at the bottom of the feet and especially between the toes.
On the mobile coach today, a medical student was taking longer with the last evaluation of the session than JOH anticipated, so he entered the examination room to speed things along. A man was relating multiple problems to the student who seemed thankful for the interruption. The man's primary problems were type 2 diabetes, a recent subarachnoid hemorrhage, myocardial infarction, and chronic pancreatic insufficiency. He was also worried about leg weakness, paresthesia, memory loss, epigastric pain, and shortness of breath. In addition, his medications had been stolen and he had been unable to replace them. He was not ill enough to require an emergency department visit. Another clinic session started in one hour but it seemed like an entire afternoon would not be long enough to address all of this man's medical problems.
JOH was able to provide some of the needed medications but, most importantly, an appointment was scheduled with him for the following day. As he was leaving, the patient asked JOH if he knew his father who had been a prominent physician in Columbus for many years. JOH certainly did know the man's father, which forged an even stronger bond between the physician and patient. This was not the first homeless person JOH had treated whose father had been a physician, nor would it be the last.
Copyright © 2002 by the American Academy of Family Physicians.
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