From a Week in Practice
Am Fam Physician. 2004 Dec 1;70(11):2100-2102.
When someone tries to contact a physician by voice mail, pager, and cell phone at 8 a.m. on the first day of the week, one has the feeling that an urgent message is being conveyed. JOH took the call from a radiologist while driving to work. Thomas was a patient who was seen for the first time the week before and had been brought in by his wife because of memory loss, falls at home, and stool incontinence. The physical examination had clearly revealed short-term memory loss and difficulty with tandem gait, but the rest of the neurologic function was intact. Blood work, including rapid plasma reagin for syphilis and heavy metal screening, had been reported as normal. What got the attention of the radiologist was an abnormal computed tomographic scan of the brain that revealed a large temporal lobe tumor showing mass effect and swelling. The plan of action at that point was to obtain an urgent neurosurgical consultation by immediate evaluation in Mount Carmel’s emergency department. JOH informed the patient’s wife of the plan and then notified the emergency department. The wife had realized her husband was not well and, in a sense, was relieved to find the cause. But, it wasn’t what they had expected. Coordinating the process of care while driving on the freeway in rush hour traffic also was not how JOH had planned to begin his work week.
The strapping middle-aged Somali patient, Yusef, had responded well to his new anti-hypertensive medication. His blood pressure was now 120/80 mm Hg. JOH, through the interpreter, MD, asked how he was feeling. “Fian” (fine) except for a kabubyo (numbness) on the left side of his chest, back, and shoulder for several days. JOH proceeded to palpate these areas with his right hand and posed a few questions: Was it affecting his work? Had he used any over-the-counter medications? What made it better? What made it worse? JOH again looked at MD, trying to understand other nuances of kabubyo. Yusef was beginning another litany of symptoms when MD came out with the all-important word, culeys (pressure). This was the word that clicked, that set in motion the next set of actions. An electrocardiogram showed abnormal ST segments and flipped T waves in the lateral leads. The next step was transport to the nearest emergency department. If JOH has learned anything in his years as a physician, it is to respect any symptom above the belt line and consider evaluation for a cardiac origin. This experience reinforced his belief, and he heaved a sigh of relief that he had not been numb to the clues that Yusef had given.
The chief obstacle for many homeless persons is not the denial of health care services, but rather the lack of skills with which to navigate the system. The bearded, disheveled homeless elderly man who knocked on the door of the mobile clinic had a tennis ball-size, fungating, bleeding lesion growing from his left forearm. It had been gradually enlarging for more than a year, and he had recently sought help at a local emergency department. “They didn’t do anything for me,” he said. JOH discovered that this was not exactly true—the emergency department personnel had simply assumed that the man was capable of following directions. The patient had been referred to a surgeon for excision of the mass, but he was unable to find the surgeon’s office. JOH cleaned and dressed the arm, and then arranged again for surgery clinic follow-up. The lesion was too large to excise on the mobile clinic and probably would require a skin graft. Transportation also would be arranged this time, but it would require a certain amount of initiative on the patient’s part. JOH hoped that, with the help of a dedicated case manager, the connection with the surgery clinic would occur the second time around.
Most of the patients on the mobile clinic come of their own volition. The usual exception is children in need of medical care who are brought by their parents. But today, there was a rare sight—a parent, Steve, brought to the mobile clinic by his daughter. The role reversal was a desperate attempt by a loving child to halt a downward spiral that was destroying her father. Despite a drug and alcohol habit, Steve had worked hard all of his life. When he stopped his addiction some years back, he had even become a counselor to others whose lives were so much like his own. He had fallen back into his old ways, however, and now had no desire to abstain from the crack that gave him the high for which he lived. What struck JOH the most, besides Steve’s refusal to try to stop the addiction that was slowly killing him, was the patient’s concern about his cholesterol level. There seemed to be a disconnect somewhere. Why bother about cholesterol when there was an elephant in the living room? But perhaps what Steve was saying was, “I want to live. I want to change my life, but not now.” Steve had at least acceded to his daughter’s wish for him to see a physician. This was a start.
NY, a second-year family practice resident, was beginning his first day on the mobile clinic. His patient, Mark, had diabetes but no medicine, and was living on the streets—a self-professed loner. He could not tolerate the shelters because of his unease around others. NY at least could help with his control of his diabetes, and talked with him at length about his other issues. “Sometimes when I’m standing on a bridge, I just want to jump.” Mark was deeply depressed, and these words indicated suicidal thoughts as well as a plan. NY was uncertain of the next step, but realized the situation was unstable. JOH recommended immediate referral to a mental health facility, but when Mark refused, the situation became more problematic. The decision was made to admit Mark involuntarily. “Have you ever done that?” was NY’s next question, more to determine the process than to learn whether it had ever happened on the mobile clinic. “We have,” was JOH’s reply, “but it’s a last resort.” A police cruiser was called, the forms were filled out, and Mark was taken to the emergency mental health center. It was not a pleasant experience, but NY had learned that the patient’s best interest is not always served when it is the patient making the final decision.
Looking out the window of the mobile clinic, JOH had an ominous feeling as Randy approached the door. A man with poorly controlled diabetes, hypertension, peripheral vascular disease from smoking, and personal hygiene that literally attracted flies, Randy had seen the mobile clinic and decided to stop for a visit rather than go to the local emergency department. He was concerned about his left forefoot, which he described as having turned black. His color vision also was questionable: when JOH removed his well-soaked sock, he saw a red, swollen, oozing forefoot with an odor that quickly permeated the entire clinic. “It’s looking better,” Randy said with a toothless grin. It wasn’t necrotic, but unless treated quickly it would end up in a specimen jar. “Unless you take your diabetes medicine, stop smoking, and take these antibiotics, you are going to lose your foot!” JOH said, emphasizing the latter. Randy acknowledged that he was a mean son of a gun (in somewhat different language), but nodded his head in agreement. JOH believed the measures were more temporizing and told Randy to follow up in the emergency department if there was any worsening of his symptoms. How Randy had survived this long with his multiple problems was a miracle in itself.
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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