Saturday, January 17, 2015

Diagnosing the Many Routes to Homelessness

Diagnosing the Many Routes to Homelessness

Seeing patients at Bozeman’s Warming Center, I find that people’s hard-luck stories often aren’t the expected ones.

By Bob Flaherty in the Wall Street Journal

Bozeman, Mont.

Some wait in battered pickup trucks or cars or vans, cigarette smoke drifting from half-open windows. Others emerge from the freezing darkness. At exactly 7 p.m., Ray opens the door and they form a mostly orderly line inside at the front desk to be assigned a locker and bunk. No pushing, no anger.
It is already below zero outside the converted machinery-rental shop that serves as Bozeman’s Warming Center for the homeless. A local nonprofit, the Human Resources Development Council, opened the center a few years ago after a homeless man froze to death in a U-Haul truck. Overnight guests must leave by 7 a.m. But for tonight perhaps no cold, lonely deaths.
I come to the center Wednesday evenings after seeing my last office patient. It is the practice of medicine at a basic level: I’m here to clean ears, trim toenails, drain abscesses, listen to worries and give advice; to fix small but important problems that will allow the people here to survive on the edge of society for another day or week. I bring a large toolbox with basic medical instruments and several over-the-counter medications.
The gas heater hanging from the ceiling works hard to warm the Warming Center, its humid mix of human smells and low conversations. As I take off my coat several guests greet me: “Hey, Dr. Bob.” They like the “Dr.” and they also like the “Bob.” So do I.
Karyn gives me a hug. “I got that tooth pulled, and it feels a lot better. Wanna look?”
I introduce myself to newcomers. Some don’t tell me their names but most do, although only their first names, and maybe not their real ones. For whatever reason, including perhaps fear of arrest, they prefer to remain submerged in anonymity; the names I use here are changed to protect privacy.
Harvey is a big man, friendly and open. His laptop is tethered to his cellphone Wi-Fi hot spot and he is, as usual, watching a streaming video—like many others, homeless in the 21st century but connected.
Harvey tells me his feet “have been hurting bad” and asks if I can take a look. He has impressive thickening of the soles of his heels, with large red cracks. I give him a tube of foot cream. “Let me know how it is doing next week.”
“Thanks, doc.” Then, hesitantly, “Why do you come here, doc?” I smile: “I’m on a mission from God.” He gets the movie reference and smiles also.
I don’t ask, but with familiarity and trust bits of their history bubble up. Divorce, lost jobs, disappearing husbands or wives, alcohol, drugs, mental illness. These homeless are often different from the homeless you read about in the New Yorker or hear about on NPR. Certainly, many have hit hard times, but just as many prefer to live off the grid. They want most of all to be left alone. They are not poster children for political assumptions.
Shah, a regular, says he is from Mumbai and has a mechanical engineering degree from Montana State University. A mystery. “What’s with that cough, Shah?”
“I have had a cold for a few days, and the cough is getting worse.” I love his clipped and musical accent. “Any hot flashes or chills?” “No.” “Let me take a listen.”
Harsh lung noises. Bronchitis, maybe asthma, probably not pneumonia. “I just gave away the last of my cough drops, Shah. Try some honey for the cough. They should have some by the tea at the Community Café.” The Community Café serves free dinners and is run by volunteers. “If you are not better by Friday, you better go to CHP and let them check you.”
The CHP Medical Clinic and the CHP Dental Clinic are part of the nonprofit Community Health Partners. I was involved with starting the medical clinic about 15 years ago to provide health care for Bozeman’s low-income individuals and families. It keeps a lot of people out of the ER and the hospital. Angels work there.
Sharon had a big crack in her heel a few weeks ago, which we successfully treated with some antibiotic ointment and a polyethylene dressing. Clearly smart and educated, she armors herself with profanity.
She describes a professional father and mother, growing up skiing and horseback riding. She speaks proudly of her knee ligament repair, an emblem of a privileged youth. No clues to why she has been a regular here this winter. Another mystery.
Working with me tonight is Tiffany, a first-year medical student at Montana State University. She is checking blood pressure for a line of men, but the blood pressure is not the point—a friendly, beautiful young woman who cares is a rare and pleasant experience for them.
I tease the men: “Hey, how come you guys don’t ask me to take your blood pressure?” They smile, but only a little sheepishly.
Jerry thinks he’s going deaf; my otoscope reveals both ears packed with wax. Tiffany and I irrigate his ears with my portable kit. Success and gratitude.
Maryn is in her early 30s but has seen a lot of miles, mostly with potholes. She has started to trust me over the last couple of weeks, and tonight, as we talk about her problems Maryn’s daughter approaches, hesitant and ready to bolt.
“I’m Trina,” she says. About 14, skinny, fleeting eye contact. Long dark hair worn over her left eye. “Do you know what this is?” Embarrassed, she pulls the hair away to show a two-centimeter mass on the left temple.
I ask if I can touch it. “Yeah, I guess.” It is soft, not inflamed. I shine a light into one side of it and it glows. “How long has it been there, Trina?” “Forever, I guess.”
I tell her it’s a fluid filled sack called a cyst and can be removed pretty easily. Sudden eye contact, wide hopeful brown eyes. “Really?”
“Sure,” I tell her. CHP might be able to do it, or they could refer her to a doctor who could do it and would take Medicaid. Trina hurries away, forgetting to say thanks in her excitement. The transformative power of a plan.
My assistant, Tiffany, will soon enter the world of 21st-century medicine: electronic health records, quality metrics, diagnostic and treatment codes, performance-based reimbursement, insurance exchanges. Medicine as process where the patient can easily get lost.
But on this cold evening she has seen a doctor helping one patient at a time, doing small things that can make a big difference. In perhaps one of the few places left in America to practice simple care and simple caring.

Dr. Flaherty practices family medicine in Bozeman, Mont.

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