From a Week in Practice
Am Fam Physician. 2004 Aug 1;70(3):481-482.
When a patient has been out of three blood pressure medications for four months because of no income, one would expect to see a blood pressure out of control. The young woman had lost her job and health care coverage several months earlier, and had come to the mobile clinic as a last resort. So, when JOH looked at the reading obtained by the nurse (112/72 mm Hg), he was surprised, to say the least. Had the initial diagnosis been in error? Had she been spontaneously cured? The questions could not be answered. JOH took her blood pressure again, and it was 132/70 mm Hg, which was still not high enough to warrant returning to the beta blocker, calcium channel blocker, and angiotensin-converting enzyme inhibitor that she had been taking previously. Fortunately, she had a home blood pressure monitor and could record the readings on an ongoing basis. She did mention that whenever she became upset, she would meditate to calm herself down. JOH encouraged her to continue the practice, which certainly would be healthier in the long run, especially if her blood pressure remained in the range that it was in today.
A week after falling onto her outstretched hand, Wanda was having difficulty holding a cup. The hand had never actually swollen, nor had it been painful, but the limitation in her activities of daily living made her seek medical help on the mobile clinic. JOH carefully examined the wrist, palpating for tender areas. When he reached the radial head, modest pressure produced no pain, but there was a palpable “clunk.” “I guess we don’t need to x-ray it—you broke your wrist.” The C-arm on the mobile clinic was, however, swung into action. It confirmed what the fingers had appreciated—a fracture of the radial head. Wanda had been using a wrist splint since the fall, having saved it from a previous bout with carpal tunnel syndrome. However, this break would require reduction and casting, and orthopedic referral. JOH admired Wanda’s stoicism, but could still not explain the lack of swelling from such a fracture.
A gunshot to the temple had blinded Arthur 30 years earlier. The fact that the shot came from a jealous boyfriend who thought Arthur was flirting with his girlfriend didn’t make the disability any easier to handle. But, another disability had begun even earlier. Arthur’s mother did not want to see a day go by without him having a bowel movement, and her method of accomplishing this goal was use of a strong over-the-counter laxative. Sixty years later, the damage was irreversible. For that length of time, Arthur required six of the laxatives every day to avoid a fecal impaction. The cost was now becoming a burden to him, along with his disability from the blindness. JOH tried to explain the dependence that Arthur’s bowels now had on laxatives but could not offer him much hope. A gradual decrease of the laxative—along with a stool softener and fluids—was the option JOH chose. A mother’s love is essential for every child, but at times it can be misguided.
Phillip returned because he “felt bad” and was out of his medicine for diabetes and hypertension. His blood pressure and glucose level were both “sky high,” but like many patients without medical insurance, he delayed his visit to the doctor until a crisis arose. He was a long-time patient of JOH, often regaling him with intimate details of his past life. A recovering substance abuser and alcoholic, he was now reaping the consequences of his previous lifestyle. Phillip rarely complained, however, and accepted his present circumstances stoically. Today, JOH wanted to evaluate his basic metabolic functions and also assess the status of his hemoglobin A1C. After the nurse tried three times to draw blood, Phillip volunteered his expertise. Proudly pointing to a vein on his index finger, he took the butterfly needle and syringe and proceeded to draw his own blood. Such skill would be the envy of any phlebotomist, but the life experience that taught Phillip this skill is not recommended.
One of the keys to escaping the pain of homelessness is finding work. When the homelessness results from loss of employment because of a medical problem, however, patients often are trapped in a catch-22. They lack the resources for medical care, especially when it requires specialty referral. One of the most difficult specialties for indigent patients to access is neurosurgical care. So, it was particularly heartening today when JOH learned of a success story. Pedro had been active all of his life until a cervical radiculopathy had incapacitated him. He had been referred to a teaching hospital’s neurosurgical clinic but was told that he needed $200 up front to walk in the door. Finally, at the physicians’ free clinic sponsored by the Columbus Medical Association, a compassionate retired neurosurgeon agreed to treat his problem. After a steroid injection to the inflamed nerve root, Pedro was like a new man. He is back at work now. Best of all, his faith in the medical profession has been renewed.
Although the mobile clinic goes to the homeless shelters to provide medical care, an even more direct outreach is a visit to the “camps” around the city, where more than 800 homeless persons live. Today, JOH accompanied two dedicated workers whose job is to provide access to medical and social services to those on the fringes of society. The experience was certainly an eye-opener. The most profound revelation was realizing the ingenuity and survival skills that go into constructing a camp. Materials discarded by society can be used to fashion shelters that provide adequate protection from the elements. Several large, sturdy, abandoned plastic shipping crates provided neat bungalows for some homeless men on the loading dock of a deserted warehouse. Many other shelters are close to railroads, bridges, freeways, and river banks. The majority of people JOH saw had no medical problems and were surviving rather handily, thank you. The more pressing needs were for candles, water, and bug spray; but one man had a large hernia and was referred for surgery. The two social workers knew all of the homeless people by their first names and showed a real respect and care for these “invisible citizens.” JOH will certainly look at wooded areas in the heart of the city with different eyes after this experience.
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.
Address correspondence to John O’Handley, M.D., 4040 East Broad Street, Columbus, OH 43213 (e-mail: email@example.com).
In order to preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario.
Copyright © 2004 by the American Academy of Family Physicians.
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