More street side diagnosis

The stuff you diagnose on the street

With the people you see and you meet

Forget confidential

Just note evidential

And hope that the homeless can eat.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  After less time off than I planned, I did some more hospital work and vacationed in Israel and San Francisco.   Any identifiable patient information, including that of my wife, has been used with permission.

Confidentiality does not apply to people who are not my patients, nor to what I can observe on the street.

The country’s homeless problem worsened in the wake of the mass mental hospital closings, an example of shameful bipartisan cooperation.

They comprise a heterogeneous group.  One summer I derived my income from my music and I made enough to eat but not pay rent; during that time I was homeless, and I found the lifestyle seductive.

Those homeless by choice, though, comprise a minority.  Most homeless have major mental problems.  No one can usefully separate schizophrenic from bipolar or addict; the Venn diagram has too much overlap.

Wonderful climate attracts not only the yuppies but the homeless, and every trendy city has plenty of both.  Alaska, where the homeless comprise part of the food chain, has a very small summer problem and in the winter almost none.

No surprise then that the homeless gravitate towards the West Coast and the Sun Belt.

I walked out onto Mission in San Francisco and observed what I could observe.

It doesn’t take Sherlock Holmes to diagnose heroin addiction in a grimy young man with a sleeping bag who injects himself on a sidewalk and nods off before he can get his syringe into the soft drink bottle he uses for needle disposal.

You don’t need much training to diagnose full-blown mania in the thin man talking fast to anyone he saw (including those invisible to others) and moving quickly without stopping.  You wouldn’t need much more to call schizophrenic the people talking to themselves and watching things only they could see.

It took much more clinical experience to diagnose rheumatoid arthritis in the twisted fingers of the man in the wheelchair who accepted a quarter from me.

On the bus, although the man tried to hide it by drumming his fingers, I saw the intermittent, asymmetric pill-rolling hand tremor and I matched it with a blank facial expression to come up with Parkinson’s.

On the street I saw a man walking with a bilateral foot drop: with every step his toes touched before heels, and he had to pick his feet up higher than normal.  I knew that he had long-track disease: something had happened to the nerve bundles running down the back of his spinal cord.  But without lab and imaging I couldn’t tell syphilis from Lyme from B12 or folate deficiency, or a mechanical lesion pressing on the spine.

Females comprised less than 10% of the homeless I saw though statistically the genders have an equal burden of schizophrenia and bipolar.  I wondered where they had gone.


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