knowing that a real physician would see her after me to verify that she received high-quality care and that I didn ’ t miss anything .
For the past year , we had been doing cardiovascular screenings in the shelter , measuring blood pressure , blood sugar and total cholesterol . If any one of these was abnormal , we recommended the patient see a provider or see us in our student-directed free clinic to address the issue . If any measurements were far beyond normal limits , we recommended they seek more immediate care . We had recommended that one woman go to the ED urgently - she was later found to be having a myocardial infarction . Unfortunately , there was a glaring gap in our strategy . It was almost impossible for the patients we screened in this homeless shelter to take return calls when they tried to make a medical appointment and we couldn ’ t reach them to remind them of their appointment with us . Most had cell phones , but their minutes were very limited , didn ’ t have text capability and most didn ’ t use voice mail . They only answered numbers they recognized , not so different from us . So even though there was a low-cost city bus service that had a stop at the shelter , follow up visits weren ’ t happening . So , we ultimately made the decision to hold patient visits in the shelter at the same time we did the screening , to ensure that no patients got lost to follow-up .
The woman with the stabbing belly pain was the first patient encounter I had in our new system . As I began talking with her , I really began to understand the difficulties that underserved patient populations in chaotic social situations deal with on a regular basis . She stated that she hadn ’ t signed up with any designated person since she ’ d moved here from Ohio several months ago , but did see an APRN at a local urgent care occasionally . Her medical history in her words included previous strokes with some slow thinking afterwards , heart attacks , stomach ulcers , frequent UTIs , COPD , DM and HTN . She was taking “ way too many ” medicines , but couldn ’ t remember the names or dosages . She said her blood pressure typically ran about “ 70 / 30 .”
She reported diffuse right sided belly pain and flank pain that had been worsening for a week . She had nausea without vomiting
FEATURE and fatigue , dysuria and dark-colored stools . On exam , her blood pressure was 113 / 65 and she had diffuse right sided abdominal tenderness that may have been a little worse in the right upper quadrant , and positive CVA tenderness bilaterally . The tenderness though varied greatly , in severity and location , with repeat exams done a few seconds apart .
Our initial concerns were for a UTI or cholelithiasis . She could not remember ever having an ultrasound examination of her abdomen . We told her our thoughts and she was agreeable with our plan . We ordered an abdominal ultrasound which later showed no abnormalities , CBC was normal , and urine showed more than 100,000 colonies of Klebsiella pneumoniae resistant only to Ampicillin . We called her and she recognized our number and answered . We suggested she see her APRN soon at the local urgent care or see us at our next visit to the shelter and called in trimethoprim / sulfa ( Bactrim ) BID for seven days .
She was one of the earliest patients in our new system , but she really highlights its success . Currently , many physicians are not available for patient appointments until weeks ahead . Urgent care provides little continuity and these are overwhelmed with each new COVID-19 wave . The individuals in the shelter simply can ’ t navigate all the obstacles . So , the ability to offer “ on the spot ” visits to these patients who are already underserved is very valuable . What we provide may be the best — and the only — opportunity for them to receive timely medical care . As a medical student , the value to my education of providing this service is the ability to take responsibility for a patient who would not receive care otherwise . It is significantly more responsibility and ownership over patient care than I usually experience , and with that , it creates a learning experience like no other . This level of patient ownership reminds me of why I wanted to be a physician in the first place : to help those who are in need .
Micah Kaiser is a third-year Trover Rural Track medical student , University of Louisville School of Medicine Trover Campus .
Dr . Crump is the Associate Dean , University of Louisville School of Medicine Trover Campus ( KMA and Hopkins County member ).