Her story started pretty similarly to any other patient I had over the past week and a half since starting my family medicine rotation. The nurse told me she had another patient who was checking in. I asked her for the name and began looking up the previous clinical notes and labs in the computer while waiting for her arrival from registration. She had a history of arthritis, GERD and uncontrolled diabetes — all diagnoses I had become comfortable discussing with patients. Her last follow-up note indicated a plan to obtain x-rays for her knee pain, metformin for her diabetes, and health maintenance screenings in the upcoming year. Although I was confused that she did not have a visit in the previous nine months, I simply assumed she would have an x-ray with some answers and hopefully have lowered her glucose at least below her previous measurement of over 400.
I was wrong.
The nurse walked in with a lady in gold shoes and a head-to-toe red outfit. As I was waiting for the nurse to finish taking her vitals, this lady in red began expressing her frustration at how long it took to get an appointment, and her worries that her J02 card expired that day. (A J02 card is a classification given out to Miami-Dade residents living under the federal poverty level, providing them with hospital services without charge.) With her bag of Easter candies and soda in hand, she was asking us to check her glucose levels, since she was concerned how high they were at the last visit. I was wondering why she was eating chocolate and drinking soda if she was concerned about her sugar level; I thought this would clearly be a visit filled with patient education about diabetes, glycemic index and healthier eating habits. As soon as the patient’s vitals were finished, the lady in red started listing off her problems to me — vaginal itching, acid reflux, “sugars,” loss of feeling in her hand, breast pain, and the list went on.
When I started asking about each complaint individually, I could not understand how someone had gone unseen with so many symptoms, each of them unaddressed and worsening over the past year. How could a patient have vaginal itching and discharge for over a year? How could a patient feel pain and a lump in her breast without telling someone? How could someone with a previous glucose over 400 stop her metformin? I remember asking her to remove her shoes to check for ulcers, and immediately the smell of the fungal infections in her toenails filled the room. However, with each complaint more of the story began to come together. She was homeless and could no longer afford Nexium; water and baking soda would have to do for her reflux. If her sister needed to have her toes amputated because her diabetes was so bad, why wasn’t the patient more concerned about her own diet? The candy only cost 50 cents and her food stamps had run out. But why did she stop the metformin if it’s free from Publix? She lost her bus card and had no way to get to Publix.
With each part of the story, her depression showed through more and more. She tried to commit suicide two months ago, but it didn’t work; she felt she even failed at dying. She didn’t understand why god kept letting her wake up each morning. Although I’d seen patients with depression most days since I started my rotation, I had never discussed previous suicide attempts. She was the second patient ever to cry to me, and the first with a previous suicide attempt. I had never seen such hopelessness, and it broke my heart.
Our approach had to change. We were no longer concerned about addressing her acid reflux, arthritis or health maintenance. Our priorities had to be about addressing the most imminent and extreme issues — her suicide attempt and controlling her diabetes. We had to mobilize the nurses and pharmacy in order to obtain her free metformin there in the clinic that day, before the pharmacy closed in a half hour and her JO2 coverage ran out, and before she fell to the risk of requiring amputation like her sister. Next step, refer her to a psychiatrist — but that costs money. We discussed with her exactly how she could obtain a homeless Jackson Card, so all referrals, tests and medications would be free and we could see her again.
By the end of the visit I felt I had just come out of a rushed whirlwind tunnel. Although our assessment and plan at the end of the visit didn’t address everything we would have wanted to at the beginning of the visit, I know we helped this patient. From her I learned to prioritize a patient’s problems, looking at the resources they have, and working with what you can. Referring for x-rays or discussing diet wouldn’t have mattered — she couldn’t afford x-rays and she ate what she could get. By the end of this one visit, I learned unforgettable lessons. I learned how to better support an overwhelmed patient who felt hopeless, as well as how to ask for help from the nurses, pharmacist, and finance department to address extreme situations. No matter the situation in life, you always have to be adaptable to change and listen for the subtle comments. By listening to the little comments about her walking to the clinic, and about her missing her family, we were able to probe further into her depression.
Medicine is an ever-changing field, whether it’s the patients, guidelines, medications or scientific discoveries. Medicine requires knowing how to adapt to change by knowing the whole story, and then working with the resources available. On the seventh day of my family medicine clerkship, the lady in red helped teach me those skills.