Archive for October, 2014

Looking but not seeing

Posted: October 30, 2014 in Uncategorized

Every time I am at the DeSales Free Clinic with students, I am reminded of how much our homeless have to teach us about the best way to practice medicine. It is truly a classroom like no other. I had 4 excellent students with me last week and so this is not a knock on their clinical skills. After all, they are still in school to learn and grow as providers. The truth is, that growth never stops (or if it does, you are doing something wrong)- but I digress.

Last week’s Clinic session was a prime example of the difference between looking and seeing.

A patient who had previously been seen by the Street Medicine hospital consult service team was discharged to the Rescue Mission and came to the Clinic last week. The students diligently went in to see him only to come back out 2 minutes later. The patient, they said, only wanted two things- 1300mg of Advil and to know when the orthopedic doctor would be here. They told me he refused to answer their questions and would not allow for an exam. What they were able to gather from a review of his last two visits, were diligently written in the subjective portion. At the top of the physical exam was written “Patient Declined” ( a small personal victory as I despise writing that the ‘patient refused’).

I took the chart, gathered my student team and went into see the patient. What I saw through my clinician eyes was a tremendous amount of information. Students in general, love to examine the patients. There are always losing points in their practical exams for skipping right over the ‘inspection’ part and diving right in to something requiring their expensive fancy-pants medical equipment. I talked with the patient and figured out his needs and how to build some rapport. He, of course, still wanted nothing to the with the ‘exam’.  I was thinking “Too late buddy, I have already completed a detailed exam without ever even touching you.” In our education area (I use the term loosely, it is essentially the 15 feet between the exam rooms and the bathroom), I asked the students what the physical exam was. They told me there wasn’t one. Interestingly, what they had seen through their eyes was confirmation that the patient wouldn’t answer any real questions and wouldn’t allow for an exam.  I walked them through the objective section of the note- we could assess the skin on his face and hands, his hair pattern and distribution, he dentition (or lack thereof), facial symmetry, eye tracking.  He had tardive dyskinesia- a side effect of too many old time psych meds that results in involuntary unnatural facial movements, fasciculation and, in his case, repeated lip smacking.I assessed his gait as he walked from the waiting room to the exam table And, I was just getting started. We talked about his psych exam and what we could deduce from our conversation. His affect, his thought process and content, his view on the future, his view about the past, his insight into his current situation.

It was an illuminating experience. Suddenly, we had a lot to say about his physical exam.

The next patient that was seen (by the same lucky pair of students) was a very soft spoken young man. He had recently had some instability in his mental health and was trying to get back on track. I saw the patient with the students after they had assessed him. Their assessments were technically spot on. However, as I talked to him, he seemed sad and lonely, disconnected to the world around him but yearning to belong. He told me he was from Tennessee and he didn’t know where anything was up here. I noted on his intake form that he had missed many meals in the last week. We talked about soup kitchens and food banks and where he could find certain things. Suddenly, I saw what I had been looking at for 20 minutes.

He was cold. And he was scared.

He had no socks on. He had on two t shirts and two ill fitting zip-up light weight hooded sweatshirts. He had a beat up backpack that was ripped at one seam.  I asked him if he was wearing everything that he owned. He was.  He was fearful because all the guys in the shelter were reminiscing about last winter and how brutally cold it was. Here is a guy from Tennessee who has no coat, no hat, no gloves, no socks and no lay of the land. No knowledge of what places will let you loiter for hours on end to avoid the cold. The students suddenly saw too and I do believe their eyes are now opened.  Small victories. Small victories.


“The common eye sees only the outside of things, and judges by that, but the seeing eye pierces through and reads the heart and the soul, finding there capacities which the outside didn’t indicate or promise, and which the other kind couldn’t detect.”

MARK TWAIN, Joan of Arc

When I was younger, I remember driving in the car across the country with my parents. I spent most of my childhood living in Kansas and Indiana but spending major holidays outside of Pittsburgh. This meant many long car rides and my mental curiosity (and predilection for asking endless questions) meant a constant stream of conciousness in the car (God bless my parents). I remember traveling down some road just off the interstate looking for a place to eat and passing a sting of ‘hotels’. I asked my parents if we were sleeping at each one- one after the other and of course the answer was no. In hindsight, they looked like aweful places to sleep with there run down fascade, their “No Vacancy” light that is missing the N, V, C and Y, their broken down cars in the parking lot and a predilection for worn out lawn chairs adorning each side of the door. How welcoming. My mother called these a ‘No-Tell Motel’ and it was only after I got older that I knew what she meant.

Most of us probrably think the same thing when we pass by these establishments that offer a cheap weekly rate, bring your pets, bring your cigarettes and whoever else you want since the front desk clerk seems to only be half in this universe and half somewhere else. An inherant bias that nothing good is happening behind those closed doors and the people who reside there are either up to no good or don’t have anywhere else to be. And afterall, idelness never leads to anything good. To be fair, I have stayed in some of these establishments in my travels and can report that nothing ill befell me, but the sour taste still remains even after plenty evidence of the contrary. Old habits, as they say, die hard.

Below is a story from Brett about how wrong we may be about the goings-on in the local No-Tell Motel. It has been edited with his permission and all relevent names have been changed.

Tom * is a 70 guy who wound up on the street medicine service after i discovered he was homeless during his nursinghome stay a few weeks ago. He worked as a truck driver his entire life until 2008 when he retired. He initially had an apartment after he retired but developed gangrene in his right leg requiring an amputation and a necrotic left heel ulcer requiring multiple surgeries. Almost all of his medical issues are related to his uncontrolled diabetes. He’s been in and out of Lehigh Valley Hospital and St. Luke’s for almost a year and was unable to keep his apartment as a result of his frequent hospitalizations. (kind of challenges that whole notion that the homeless are just alcoholics who eventually had to pay the piper huh?) He does get about $900/ month in social security, but the lowest cost apartments are $700/ month and his meds cost over $200/ month. With no support system, no family, and only 1 friend in a similar situation as his own, he became homeless.

After a recent hospitalization, he was discharged a few weeks ago from a local short term rehab facility to a “no-tell” motel. I pass this motel often and think about how horrible it looks, and the bed bug infestation that must be occurring as I drive by. My suspicions were confirmed by reviews of Trip Advisor and I wonder how anyone would let a human they cared for stay there. Not only is Tim 70 years old with severely uncontrolled DM but he also has a severe tremor making it impossible to check his own sugars. The rehab facility discharged him to the motel with all of his meds, but no supplies to monitor his sugars even if he had the ability. He also had no hime care services set up- no visiting nurse, no meals on wheels.

I visited him the day after discharge and brought him diabetic supplies and supplies to care for his leg wound. I was appalled at the condition in which he was living. He had no access to food and was living off pizza from the shop next door. His fluids consisted on soda from the machine outside his room. The bottle then became a urinal and he had multiple bottles of urine stacked up by his bed. He assured me he would be ok, which of course I didn’t believe, so I returned the next day. Upon my return I found him and his room covered in vomit and he looked like he was going to die. I checked his blood sugar and the meter read, “HI,” meaning his blood sugar was greater than 600. He adamantly refused to go to the hospital because he, “had it with those people and would rather die.” I cleaned him up and brought him some food, but despite my pleading, he stayed.

I called Area Agency on Aging, the VNA, and the Conference of Churches, anyone I could think of who might be able to help me. Two days later I returned to find him looking MUCH better. It turned out that over the past two days the motel clerk and another motel resident had been helping to feed and bathe him. They dressed his wound with the supplies I left, administered his meds to him, and cared for him like a family member. A few other motel residents who were diabetic were coming to check on him regularly.

I thought about community building that occurs when one is all alone, similar to the communities I find in the encampments. If I give a sandwich to someone who is hungry, they will always share with their friends. I don’t know if the same type support and love shown for my patient would have happened at the $200 a night hotel down the street. I realized my own unconscious bias for this motel and will never look at it the same again and I give credit to the fellow inhabitants of the no-tell motel who supported this man when our system let him down.

I stand corrected.

The Homeless – 39 Questions For Your Reflection.

In the Spring of 2013, Brett came across a conference being held in Washington, DC a few weeks later. We scrambled with our employees and our families to find coverage for the many hats we wear and off we went to the National HealthCare for the Homeless Council conference.  I have been to many, many educational conferences in my professional career and I can say that up until that point, none of them would be described as life changing.  Prior to our attendance, we had been running the DeSales Free Clinic since 2007 but had not really met other people who were doing the same things. Two things happened at that conference that changed the trajectory of our lives.

First, we were able to see that what we had created at the DeSales Free Clinic was as comprehensive and well thought out as many of the programs who were presenting their healthcare models at the conference. We always felt in our hearts that what we were offering was logical and right but we really had nothing to compare ourselves to. The second thing was that we were able to meet all of these people that were offering healthcare to their homeless population in ways we had never even thought of.

It was like a mental explosion.

I remember sitting at a restaurant with Brett after the conference was over.  We made a plan at lunch that day about what we wanted homelessness medicine to look like in our area. It was suddenly blinding that what we were doing was great but there was SO MUCH MORE that needed to be done. More people, more locations, more populations, more awareness. For both of us, a sudden and sharp vision (blessing)was born.

We wanted to start with developing a Street Medicine Program. We don’t really know how to do anything small and so considering starting something in a logical-one-step-at-a-time method is a nice theory but we know we’ll blow it right out of the gate. We knew that the biggest job was two fold- 1) convince important decision makers that the Lehigh Valley has a homelessness problem and 2) Get buy in for this never-heard-of-it-before type of medicine called Street Medicine.

A few months after the NHCHC conference, we attended the International Street Medicine Symposium in Boston, MA. Again- mind blown. The benchmark program- Boston Health Care for the Homeless Program- hosted the conference and I thought our heads were going to explode on the car ride home.

Today, Brett starts as a full time Street Medicine PA in the Lehigh Valley Health Network Street Medicine Program. He has worked tirelessly at the hospital and had more meetings in the last year than I think he ever thought possible. It’s funny but Brett is more of a do-er and less of a talk-er but he knew that he had to get people to see the vision as clearly as it lived in our heads. He met with grants people, finance people, security people, mechanics, community partners, HR, PR, IT, development, department chairs, managers…he learned about departments that we never knew even existed. And amazing people who were willing to help in any way that they could to give this idea legs.  Their eyes were opened and all of a sudden, they couldn’t imagine why we hadn’t thought of this sooner. He did lunch meetings, breakfast meetings, stand in the hall and chat meetings. The goal was to create an idea so big that once your ready to ‘go live’, it would be nearly impossible to stop. Their eyes were opened and all of a sudden, they couldn’t imagine why we hadn’t thought of this sooner.

Everyone has a different dream and I feel like very few get to wake up and do what is living in their heart all day. There is a pure joy that escapes unabashedly out of a person when they are doing what they love. Today is that day for Brett.  Dream big or don’t dream at all.

” It ain’t about the money you make, when a record gets sold, It’s about doin’ it for nothin’, ’cause it lives in your soul.”  – Eric Church