Train Station Waiting Room in Winter

It was 6:30 am on a Thursday in January and Tom was in the lobby waiting for the 7 am train. There were four homeless people wandering around: three women and two men. It was 30 degrees and they were trying to keep warm. Police officers were circling around them like sheep dogs and rousting them to make room for passengers.

While Tom was looking at the revolving train schedule to find his track number, he noticed a man with gray hair tied in a pony tail and wearing a dirty green down jacket. Tom saw a slash across the back with down protruding from the wound. He wondered what caused the gash? A knife, a piece of glass, or barbed wire? Was it due to an accident, or a fight? As he walked, Tom saw the man stepping gingerly on his left foot.

George had stepped on a sharp stick while hunting. The stick penetrated his boot and entered his foot in front on his left heel. A few days later, the wound became red, swollen and hot. Tom drew two sets of blood cultures and treated him with antibiotics. Blood cultures were positive and Tom adjusted the antibiotics. The patient improved but the infection did not resolve. Tom treated George two more times, until finally the patient was admitted to a hospital where the wound was explored surgically and some threads from his sock were found to be the nidus of recurring infections- after the wound was cleaned the infection resolved.

An officer said to a gaunt looking woman coughing on the bench: "what are you waiting for?"

"He LEFT me here." Tom wondered was she making up the story, or had someone really deserted her? And if so, why? Was she infected with HIV and/or TB?

Marie had vertebral osteomyelitis. Tom treated her for presumed staphylococcal infection with antibiotics. Her condition failed to improve and a biopsy showed the organism was TB, which required treatment with four anti-tuberculous drugs (pending culture results). Had a biopsy not been done Marie would have suffered vertebral collapse and risked paralysis.

Another officer pointed his baton at a disheveled elderly man and said: "young man, what are you doing?" The man had difficulty hearing in his right ear, mumbled incoherently and looked off in the distance.

Jack was a businessman who had been having symptoms of gallbladder disease- right lower quadrant abdominal pain and belching. He toughed it out and went on a business trip to Mexico where he became very ill and jaundiced. He flew home, had his gallbladder removed. Post-op, he had abdominal pain and was treated with Demerol a fast acting pain med. Subsequently, he "saw heads of Mexicans floating by my bed" and thought he was in a casket due to the flowers in his room. Tom suspected Jack was withdrawing from alcohol. His wife knew better. Jack was having an adverse reaction to Demerol, but also had a life-threatening infection. Luckily, Jack's wife had worked for an excellent internist, so she demanded an emergency infectious disease consult who started Jack on antibiotics and correctly treated ascending cholangitis due to a gall stone impacted in the common bile duct. Had this consultant not seen Jack, he would have died in the next 1-2 days. The price for antibiotics was 90% hearing loss in his right ear.

Sitting across from Tom, a morbidly obese Caucasian woman with a small head and a huge abdomen stood up from the wooden bench.

"OK, I didn't want to sit next to these funky people anyway."

Tom smiled, because he was wearing a suit and was one of the ones whom the woman didn't want to be around. She limped away waving her cane. Her obesity may have been due to starvation followed by binge eating. Tom noticed her fingertips were black.

Lisa was on steroids and had a kidney biopsy. A day later, she developed low grade fevers followed by a change in mental status. A nurse noticed black spots on the patient's fingers. Tom told her "put Vaseline on her fingers and wrap them in gauze." Her husband knew there was something terribly wrong with his wife and had her transferred to another hospital. An astute physician took one look at Lisa's fingers, wiped one of them with alcohol, took a sterile needle and unroofed one of the black spots, made a smear on a slide, heat fixed it; Gram stain revealed blue colored, grape-like clusters of organisms-classic for Staphylococcus. The diagnosis of staphylococcal bacteremia (due to the biopsy) was made. Had it not been for this 5 minute procedure, Lisa would not have received antibiotics and died.

Tom remembered homeless people coming in the ER of the tertiary care hospital where he trained. In winter, some of them slept on cardboard over steam grates. These poor people would present with their flanks charred-like grilled fish.

Tom tried to imagine what it would be like to be homeless? He thought of bivouac during Army basic training at Ft. Lewis, Seattle, Washington. He spent a night sleeping in a two man pup tent in the snow; they had to set it up in the dark and the tent collapsed at 3 am. His boots were soaking wet and the only way he could dry them was to put them in his sleeping bag. Tom was never so glad to see the inside of a building after returning to our barracks. One cold night outside was enough for him.

Tom caused harm to all four people in different ways by violating his mentor's Oath- "Don't treat blindly," meaning know what you are treating. There is another saying in medicine- "if you don't think of it, you won't diagnose it."

Tom remembered a 90 year-old nursing home patient named Jimmy who used to

point to the sky say : "Justa remember every thinga you do is inna the BOOK"

Further reading: "Nowhere Else to Go."

"An Educated Consumer."