TBSM On The Sea

I would like to thank twitter for giving me the idea for this blog post. Externships, residency applications and frequent episodes of “future tripping” have made it difficult to reflect back on TBSM this summer. My apologies. Luckily everything changed when I went to Kansas City, Missouri (not to be confused with Kansas City, Kansas) for the American Academy of Family Physicians (AAFP) National Conference. At the opening session, conference leaders asked everyone to tweet throughout the weekend so last year’s conference record of 26 million twitter imprints would be surpassed. I felt obliged to do my part, because I was very grateful to be attending the National Conference on a scholarship from the AAFP. While the opening session was still going on, I made a twitter account. Feel free to follow me @ari_crocker.

I started following people on twitter and soon enough I came across the twitter account of the Dalai Lama. After scrolling through the Dalai Lama’s twitter feed, I saw one of my favorite quotes of his: “Just as ripples spread out when a single pebble is dropped into water, the actions of individuals can have far-reaching effects.”

I have read that quote many times and each time I am reminded of something different. But today, I thought of my first TBSM Seafarer’s clinic. To be specific, the very end of the clinic when our Port of Tampa liaison was dropping us TBSMers back at the port entry. He said in reference to the Seafarers working on the cargo ships, “These men don’t mean much to many people, so thank you for coming.” My heart sank. What a heartbreaking, yet unfortunately truthful, thing to say. The men who we cared for are at sea for months at a time. They often to do not get paid until the route is complete so they don’t have money to buy necessities when they stop in ports. Also, many do not have the right visas or paperwork to legally leave the ship while in port. After spending the afternoon on the cargo ships with the seafarers and having the liaison put into words how he felt, I cannot imagine a better fit for a TBSM expansion clinic. For those who haven’t had the chance to go to a Seafarer’s clinic, I highly recommend it. The men we met were so kind, gracious and fun. The small amount we can do for these men might seem trivial to some, but it is not. This clinic might be there only medical care throughout their months at sea, what a honor that we get to be there for them. The once small ripple that is TBSM is spreading farther.

Tips for Seafarer’s Clinic:

• Medical supplies and hygiene are the same as for street runs.

• Blood pressure checks for everyone who comes to the clinic is a nice way to break the ice.

• Many seafarer’s might not have any medical issues but want to talk about life in Tampa, sports teams, music or movies. Make sure to leave time to just hang out. This is a nice break from their routine.

• Bring a government issued ID

• if you have an extra hardhat lying around, bring it!

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A Reflection

As we round out the end of another school year, it gives us all the chance to reflect on our experiences. It’s a bittersweet moment. We’ve learned a great deal with countless and sleepless hours spent pouring over the books. Yet, we look back at it with pride and love. Our patient interactions, especially those on street runs and in clinic, are what we end up treasuring the most. These conversations and connections that we build are what we remember from the year.

In the past, TBSM would often set aside time after a street run or clinic for the group to take some time and reflect on their encounters. We urge all of you do to take some time before the hustle and bustle of the new year starts to reflect on some of these experiences. I am always amazed that the smallest conversation can leave the biggest impact. Often times they aren’t even medically related. Instead, they offer a little glimpse into the patient’s life and their universe. This is what continues to drive me during those long hours. These stories remind us that we get the privilege to play a role in their story. We are just another character in their incredible stories.

I recently found a poem in JAMA that spoke to this point so clearly:

Street Rounds

By Cordelia Yen Ross, MD, MS

Today, I sat on a bench outside

the hospital, surrounded by twelve street people,

including one man

with a guitar.

It was one of his three prized

possessions (the other two were a pair

of crutches). He had kind eyes

and rotting teeth.

He introduced himself and took my hand

and he shook it firmly. With comfort

and with confidence.

Why shouldn’t he?

He spoke of his travels, beginning

with his service in Iraq and then Japan,

where he learned

to say “you look pretty.”

He described his fight in the ocean

with the 5-foor shark that attacked his leg;

he still has scars and a limp

to prove it.

Then, he played a tune for, an old county song

from his childhood. He sang along

while I played

a few chords myself.

There was nothing he needed

from me. There was nothing he had to prove

to me. For that moment in time,

we sat

as two people, with a common love

for music, enjoying an unusually warm

Fall morning, in the park,

together.

Find more poems here: https://jamanetwork.com/collections/44062/poetry-and-medicine

Tips for Medical Teams!

• When on street runs, approach patients in groups of 1-2 students.

• Make sure to hand out fliers of where our clinic is and what dates it will be open.

• Mention that our First Presbyterian Clinic now has rapid HIV testing!

• Remind them it is our pleasure to serve the community and that we hope to see them again!

• Listen to the patient and understand their concerns before interjecting. Be engaged.

• Sometimes all they need is a conversation with another person.

• Share with other pedestrians what we are doing and what TBSM is all about.

• If they don’t have any medical needs, offer them hygiene supplies.

Homeless Veterans

I remember my first encounter trying to help someone who was homeless or displaced. One

day on my way to class, as an undergraduate, I was stopped at a light where a middle-aged gentleman was holding up a sign, ‘Vietnam veteran, homeless and hungry, anything helps.’ I had just returned from my second overseas deployment. As a member of the military we are taught to look after one another. Here at this stoplight was an above-the-knee amputee on crutches. I couldn’t drive by and continue on with my day like I didn’t just see someone in need, so I stopped and talked with him. As a veteran who has benefitted from the VA Health System, I talked with him about ways to get him help. What ensued was a 6-month long relationship, where we would talk routinely (him by calling me on a payphone and meeting up) and I would try to help connect him with veteran services. During this time, I was able to help him gain some stability, but we unfortunately lost touch (I stopped receiving calls and stopped seeing him in his usual spot). I never got a chance to know if he regained housing.

I didn’t know street medicine existed prior to starting medical school, but when I learned what TBSM did I had to take part. Providing medical care to those who have nothing or next to it. What could be more important and impactful as a medical student? In the four ensuing years I have had the privilege to serve and treat members of the homeless community and see some of them become stabilized. Being a veteran, I tried to leverage my background to identify and connect veterans to Veterans Affairs. I have learned so much from the people I have met while being a member of TBSM and have had the opportunity to see TBSM grow into what it is today. The students who volunteer their time as leaders and student providers are some of the brightest, most-humble, and kindest people I know. Being a member of TBSM has been one of my most valued and proudest experiences in medical school.

The veteran I tried to help prior to medical school, unlike some of his homeless veteran peers, was already connected to the VA. He had a service-connected disability and received benefits from the VA. He had a house and rented several storage units. As I got to know him better, I learned that he was evicted from his house due to failure to pay his mortgage, and his house was in foreclosure. When asking him why, when he had a stable income, he said he had to pay fines due to issues with the storage unit complex, but he was now locked out of them too! I ended up going to the storage unit facility one day to ask about what was going on with his units. The management talked at length about him and his units, how he collected and put garbage in his units (literally not figuratively) and was living in them. They talk about how they had warned him and tried to work with him, yet he kept disobeying the facility’s policies. After several times, they started sending him fines. After he did not stop and did not fully pay the fines, they locked him out of his units. He would have to pay the fines before having access to his possessions and then afterwards he had to relocate his property. Complicating his situation, since at the time he lost his housing, he had no address and was not receiving his disability income – making him unable to pay the fines. Just prior to losing touch, I tried to help him get reconnected with the VA to get his income and in an effort to resolve the fines and regain access to his property.

I didn’t realize it at the time, but looking back, it is likely he had an underlying mental health disorder that was either undiagnosed or untreated. So many homeless individuals, like him, have an undiagnosed or untreated mental health disorder. The National Coalition for the Homeless estimate 20-25% of homeless individuals suffer from a severe mental health disorder. While volunteering at the street medicine clinic, I have seen many homeless patients with mental illness in the clinic, more than I would like to count. A complicating and unfortunate factor for many of these individuals, who lack stable housing and income, is that they go without the very thing that may offer them the ability to regain housing and an income – medication and therapy. Many of the medications for severe mental health disorders have risks, and follow-up (which can be especially challenging) with these individuals who initiate therapy is critical. In addition, it often takes special effort and time to build trust and rapport with these individuals before the topic of treatment can even be broached with them. All of these barriers to care regrettably complicate our capacity to treat these individuals.

While a member of TBSM, I have seen TBSM grow from just one street run to having a clinic, outreach runs, and most recently a mobile unit. Partnering with community organizations has been vital to street medicine’s growth. I have had the privilege to be involved in building some of these community relationships that have positively affected our patients. As a result of this effort, we have improved our capacity to treat members of the homeless community, including those with mental health disorders – but there is still a way to go in helping this sub-population. I look forward with eager anticipation as future leaders continue to build upon the progress of their predecessors, to find new and innovative ways in overcoming the barriers to caring for this population.