The New Bathroom

A typical shift at Occupy Medical is pretty serious business. We work long hours, without pay, in all kinds of weather with people who are suffering from sadly neglected medical conditions. For the last year, we have done all of this work without access to a bathroom. Imagine our delight, when the city offered us a free porta potty. Obviously, we are grateful.774565_193986244077694_697280682_o

 OM’s sparkly, new alter-able bathroom

The bathroom was huge hit. Our practical volunteer Benjamin’s 1st thought when he saw this big, blue wonder was, ” I could’ve had another cup of coffee.”  The luxury of a clean bathroom was not wasted on our patients either. Now we can give urine based tests such as pregnancy tests. This is the start of even better service at the Sunday OM Clinic.

The girls in the nurse’s station organized a grand opening. Susan suggested a toilet paper cutting ceremony instead of a ribbon cutting ceremony.  As you can see by the photos below, we loved it. Good call, Susan, good call.774462_193986324077686_987077852_o

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Deep January clinic. (by Dr. Leigh)

Dude. Winter is here. Winter is here, and we’re making it – most of us.

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One patient said, “Remember, you told me to quit smoking a few months ago? Well, I did it.”

Another said, “The blood pressure medicine you gave me last time? It’s working.”

Another said, “I ran out of refills last week. I thought I was just S.O.L.” [“Seriously out of luck.”] (I changed their dosage by a few milligrams, and saved them $40 a month. In other words, I made it possible for them to have any medicine at all, since they didn’t have $40.)

One patient needed, in my estimation, a “simple” skin surgery – simple under normal circumstances, but here? They came back after 2 hours, as I’d asked them, to get a second opinion. In the meantime, they got a tetanus shot. The second-opinion doctor examined them carefully, and finally said, “You should just come into my office, and I’ll do it for free.” Like I said, simple.

The Public Health Department nurses were there, giving free tetanus/pertussis vaccinations, and hanging out with us. We had new nurses. We had a full Triage team, like a well oiled machine. We had new volunteers helping keep track of patients and their medical records. (We take health-record privacy very seriously.)

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Over in the tent, we had a big crock pot full of hot vegetable bean stew; hot tea; home baked bread. Donna said, “I’m still trying to give away these boots,” indicating a large pair of insulated leather-and-rubber winter boots. I got my hair cut in the tent, chatting with a friendly social worker while Benjamin made me look stylish. Food Not Bombs came and set up next door, with more hot soup and bread for everybody.

We have pretty earnest, good-hearted fun at the Occupy Medical clinic. I had a student with me, and I was telling her, This clinic is for everyone, for free, every Sunday. We see a fair number of people who are unemployed and unhoused, and don’t have many resources other than their wits and good looks, but it’s mainly because of where we park the bus, downtown.

If we parked the bus in the Wal-Mart parking lot, we’d still be super busy all afternoon, with people who might have houses to go home to, but they mostly would still lack proper health resources, such as insurance that pays for doctor and dentist visits, lab tests, x-rays, and medicine.

And If we parked the bus at the health-food supermarket, where people go to get their fancy French cheeses, organic blueberries, and herbal toothpaste – we’d still be busy all day. Just because you have $10 to buy a gluten-free frozen pizza, doesn’t mean you have $250 for a single doctor or dentist visit – or $600 a month for health insurance.

No matter where we go, there we are! No matter where we park the Occupy Medical clinic bus, we’ll always be busy, because injury and illness happen in every social class, and people are falling through the cracks in our broken social system at faster and faster rates, as service budgets are cut and insurance premiums rise. This is why, at Occupy Medical clinic, we don’t ask people to prove they’re poor enough to deserve our services (or rich enough to “make it worth our while”). Health care is a human right, not a scarce commodity.

Meanwhile, since we are parked downtown on a Sunday afternoon, we see a lot of folks who’ve been getting really cold. And we get cold, too. It’s cold! When I got out of my nice warm bed this morning, the online newspaper said it was 28 degrees with “freezing fog.”

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We’ve had freezing fog for a week now. I’m seeing more people with bad asthma attacks from it. One guy called it “cold smog.” Today I saw one person with pneumonia. She called it “Occuplague,” after the terrible bronchitis people got last winter in the Occupy camps, nationwide, from living outside. I told her, your lungs sound like a teakettle that’s boiling – they’re gurgling. My little pulse oximeter showed she wasn’t getting a normal amount of oxygen into her blood.

The shelters generally kick everybody out, every morning, no matter what the weather, so people have to basically walk around all day, if they don’t have a job or school to go to. Last week I took a photo of the view out the window, where I work on the bus. The ornamental pond across the street, with the metal fish sculpture in it, was covered with little icebergs. It’s so cold, and folks are obliged to just kind of walk around all day. So they get sick.

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Did you know that the other local do-gooder low-income clinics are now over-full, and can’t take new patients? One administrator came and visited us a couple weeks ago, to ask, hopefully and apologetically, if we will be able to handle the patients they can’t.

But it’s not all bad news. There’s a lot of good news. I get patients coming back in to show me that they got better, with care. Also, after months of wrangling, protests, and peer pressure, the City has provided the Clinic with a porta-potty. This makes a huge difference! For example, it makes life much easier for our volunteers, who stay on the site for 4-6 hours at a time, often coffee-fueled and unable to stop their work to hike down the street and buy something in a coffeeshop, for the privilege of using a bathroom. It’s also a service to our patients – can you imagine what it’s like to try to get to the doctor for a severe gastrointestinal ailment, or to take small children downtown to be seen, and there’s no bathroom? We can also do pregnancy tests and simple urinalysis now. It’s just incredible. It’s practically “first-world.”

The City has also allowed us to plug into the park’s power supply – after we took out an extra-large insurance policy protecting the City from any lawsuits – the kind of insurance policy that would be appropriate for a giant rock-and-roll show. Oh, well. At least we have lights – and a wee space heater, at the chilly doctor’s elbow.

We’re feeling pretty fat and sassy, now, in fact, with our fancy electric lights, and our porta-potty, and our hot drinks and pot of soup. Benjamin, the guerrilla hairstylist, can even run clippers and a blow-dryer, as I found out myself today. Stay tuned for the Friday clinic, staffed by a heroic team of nurses – a dedicated Wound Care Clinic. By golly, if elected officials can’t figure out how to provide health care as a human right, we’ll just have to do it ourselves! We could be heroes, just for one day.

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Occupy Medical clinic is tremendously excited to welcome any new volunteers who can offer any skill. Particularly needed are additional primary-care doctors, nurses, pharmacists, caring-profession students and trainees, dentists, dental hygenists, certified herbalists, veterinarians, pet groomers, licensed bodyworkers, counselors, social workers, mechanics, engineers, bus drivers, roadies, bouncers, organizers, fundraisers, statisticians, publicists, printers, artists, photographers, seamstresses, group facilitators, workshop teachers, friends, neighbors, cheerleaders, and people to help set up and tear down.

About the Public Health Department vaccine programs: http://www.lanecounty.org/Departments/HHS/PubHlth/Pages/lcph_immunizations.aspx#adults

About Food Not Bombs: http://www.youtube.com/watch?feature=player_embedded&v=_jZKjBVXGJI#!

Chaos

Chaos* is the science of surprises, of the nonlinear and the unpredictable. It teaches us to expect the unexpected.

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My daughter came back to town after finishing midwifery school. She needed a ride downtown to meet a friend for coffee. She came with me first to the five-and-dime, where we bought an electric teakettle to heat up water for the Wound Care nurses, at the Occupy Medical bus. The teakettle was really very pretty: dark red chrome. She helped me carry stuff: my doctor bag, and the teakettle, etc. I introduced her around. We were early: it wasn’t time for me to start seeing patients yet; Dr Peter was on board.
 
The Butterfly Effect: Small changes in the initial conditions lead to drastic changes in the results.
So we filled up the red teakettle, first asking about the status of the water (potable) and figuring out how the faucet works on the bus (you have to pull a knob). We plugged it in and turned it on, and all the lights went out.
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Everybody went, “Woahhh!” and looked at each other. My daughter and I whispered to each other, “Did we do that?” Dr Peter opened the blinds where he was working with his patient, and after a minute, he called out, “Can we get the lights back on?”

I went outside to look for one of the engineers, and Nurse Bill said to me, “You start from the back, I’ll start from the front, and we’ll try to find a fusebox.” When I went back inside, James was already flipping breakers, trying to find one that would work. We unplugged our pretty red teakettle.

Unpredictability: Because we can never know all the initial conditions of a complex system in perfect detail, we cannot hope to predict the ultimate fate of a complex system.
After a while, some of the overhead lights came on, but flickering. Dr. Peter’s lights still weren’t on. People kept calling back and forth, “Is it working now? Now is it working?” “Naw, still out!” “…How about now?”

Chaos explores the transitions between order and disorder, which often occur in surprising ways.
Dr. Peter’s shift was over, and my daughter helped me to quickly wipe down the entire doctor’s area with bleach wipes, like we always do at shift change. Our new Triage EMT, Elliott, asked, “Do you need a medical interpreter for Spanish?” I looked at my daughter, and we both grinned. She’s an activist who just spent the past year and a half learning how to be a midwife, entirely in Spanish. How convenient!

Together we saw a patient with a bad tooth, using a flashlight and the scant daylight through the window blinds half-closed for privacy.

The patient had a friend once who died from an abscessed tooth – most likely septic shock. We were able to discuss this concern in detail, because we happened to have the right interpreter, and happened to ask the right questions, at the right time, on the right day – even though we blew the lights.
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Turbulence ensures that two adjacent points in a complex system will eventually end up in very different positions. Mixing is thorough because turbulence occurs at all scales.
My daughter went back outside with the patient, and the antibiotic prescription, and got them signed up for our upcoming Dental Clinic, where hopefully that bad tooth can be permanently fixed.

The lights came on. My daughter went to the coffeeshop. I started seeing patients with complicated issues – a few with simple issues, thank heavens, but as usual, I got behind. More and more behind. There were others with infected teeth, one diagnosed with a skin condition at an urgent-care site but not treated, one with pertussis who’d been prescribed an over-the-counter antihistamine, at another urgent-care site…

Systems often become chaotic when there is feedback present.
…People with digestive or urinary problems, needing a good explanation of what might be going on, to properly manage and treat them. People prescribed $150 brand-name medications they can’t afford, when $4 equivalents are available. People with medical complexities that are like Russian nesting dolls, one ailment enfolding another, with yet another at the root. A medical system so difficult to navigate, that many patients come to us simply to ask directions for it, or to get a translation from ‘Medicalese’ to ‘Plainspeak’.
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Running late, just at the time we’d normally close, I got down to my last three charts. But a radio journalist had been waiting for a long time to have a quick word with me. Sometimes, all the work in front of you is time-sensitive! We sat together and spoke for a few minutes. I gave my pitch for volunteers. Doctors! Nurses! Veterinarians! Dentists! Two hours ain’t bad! If you have just two hours a month to give to your community… well, that would be fantastic.

Fractals: Infinitely complex patterns, that are that are self-similar across different scales, are created by repeating a simple process over and over in an ongoing feedback loop. Driven by recursion, fractals are images of dynamic systems.
Everybody’s phone pinged. “Blizzard Warning until 6 pm Monday night.”

Huh?! …It wasn’t just me. Nobody else had had their phone suddenly alert them to an approaching blizzard before, either.

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Outside, the wind picked up, and the Intake tent became a very heavy box kite. Volunteers, including the radio interviewer, leaped over to rescue it. I could hear tent poles clanging as I finished seeing patients, long after everyone was ready to hurry home in the dark, through the 50-mph gusts.

It’s a good feeling to tuck everything away at the end of the day, restoring a temporary illusion of order from the day’s chaos – boxes of gloves back in the drawer; dermatology atlas, wilderness-medicine and other textbooks back in the cupboard, sharps box and ear-scope tips put away, homemade public-health flyers and bottles of hand sanitizer stowed – and, of course, the fatal teakettle.

It really is very pretty.

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*from http://fractalfoundation.org/resources/what-is-chaos-theory/

by Dr. Leigh (Leigh Saint-Louis, MD)

Windy Day at OM

12/16/12 – Occupy Medical volunteers called all hands on deck as 45 MPH winds threatened to pull our intake tent from the ground. A visiting reporter from KLCC jumped into action with other seasoned volunteers as the 20 foot long, steel framed portable canopy filled with air like a giant box kite. We held the held the poles tightly as James placed filled 5 gallon water squares on the wooden supports. Clearly, the cement cider block weights were not enough.
When I tell stories of our adventures at Occupy Medical, some people narrow their eyes with doubt. The tragic tales of our patients, the valiant deeds of our volunteers, the generosity and diversity of our donors and the obstacles that we all face from the weather, the authorities and from the limit of our resources just seems unreal. This time we had a reporter there to witness it first hand.
This reporter cut her teeth on radio news. She has been doing her job for close to 20 years now. She observed the flow of the clinic. She asked in-depth questions. She got a tour of the bus. When she asked to interview a patient, I grabbed the first patient to come out of the bus.
I went back into the med tent to check in with the volunteers and make sure that we were out of danger. A few minutes later, the reporter came back into the tent. She was holding back tears. She explained that as the patient started telling his story, he broke down. This seasoned reporter was so moved that she started crying even as she held tightly to her microphone. The clinic got her. It does that from time to time.
The reporter turned to me and asked I ever get used to all this. I looked around. I saw the piles of donations, the shivering patients being warmed by our oil heater, the volunteers comforting new patients as they waited for their turn to see a doctor. No, I thought, I really never get used to it.
Occupy Medical is different every week. New patients, new wounds, new stories. It tears me up and inspires me in a new way every time. It’s got me.
– Sue Sierralupe, OM Clinic Manager

The United Nations on the right to pee safely

From the United Nations “Report of the Special Rapporteur on the human right to safe drinking water and sanitation,” 8/2/2011

“In some cities, homelessness is being increasingly criminalized. Criminalization includes fines, arrests and severance of social protection benefits or even access to employment.

“Local statutes prohibiting public urination and defecation – which can constitute a sexual offence in some cases – while facially constitutional to protect public health, are often discriminatory in their effects. Such discrimination often occurs because such statutes are enforced against homeless individuals who often have no access to public restrooms and are given no alternatives.

Furthermore, there is an increasing trend in local governments to limit opening hours or close entirely public restrooms.

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“…The independent expert visited a community of homeless people in Sacramento, California, where she met a man who called himself the “sanitation technician” for the community.

“He engineered a sanitation system that consists of a seat with a two-layered plastic bag underneath. Every week Tim collects the bags full of human waste, which vary in weight between 130 to 230 pounds, and hauls them on his bicycle a few miles to a local public restroom.

“Once a toilet becomes available, he empties the content of the bags; packs the plastic bags with leftover residue inside a third plastic bag; ties it securely and disposes of them in the garbage; then sanitizes his hands with water and lemon. He said that even though this job is difficult, he does it for the community, especially the women.

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“The fact that private citizens are compelled to provide such services is an indication of failure by the State to meet its responsibilities to ensure the provision of the most fundamental of services.

…[The UN expert advised, among many other points, that the United States] “Ensure that all municipalities provide access to safe drinking water and sanitation to homeless people, including through ensuring the opening and regular maintenance and upkeep of public restrooms, as well as availability of public water fountains, including during the night.”

http://www2.ohchr.org/english/bodies/hrcouncil/docs/18session/A-HRC-18-33-Add4_en.pdf

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(posted by Leigh)

What a Busy Sunday

The sky was gray, a gust of rain occasionally spitting. Quite a while before we opened, a dozen people were in line. Deb, our intake coordinator, kept moving back and forth, between practitioners and patients, maintaining a coherent flow, against the odds – like herding cats, as they say.

At first, I was committed to working cooperatively (as a physician on the bus) with our nursing students, but since we were at capacity almost immediately, rapid “processing” of ill, injured, and worried humans took precedence over thoughtful collaborative education, and we separated to each perform our separate duties.

We were blessed with a three-nurse team, who cared for people with wounds and complicated self-care issues. Dr David appeared out of the blue – I hadn’t expected him! – and took over on the bus for a couple of hours. I went out to visit with people on one of the rain-soaked park benches, getting all but the physical exam, to try to “cut down on the list.”

A number of patients couldn’t wait to be seen, and had to leave. I think we can start giving people estimated wait times, just as you’d do at a popular restaurant: count up the number already on the list, and multiply by 12 minutes each. Ordinarily, we see about 20 patients per four-hour day, so that would work: ordinarily, a visit would average twelve minutes or so.

Twelve minutes is not enough! However, we just don’t have unlimited resources. People really need medical attention. So we try to move people though as quickly as is practicable, and hope they don’t feel uncared-for.

This Sunday wasn’t ordinary, though! With two doctors available part of the time, we saw 27 people. Average, eight minutes and fifty-three seconds a visit.

Eight minutes and fifty-three seconds is not enough.

“How can I help you today?” We* sit down on the wet park bench.

A terrible pain in the belly – a recent bereavement – a stressful new job with a lot of heavy lifting (kept just under full-time, so no health insurance would be offered). Couldn’t afford the tests the old doctor wanted (and now the old doctor refuses to follow up due to past due doctor bills); high blood pressure and keeps forgetting to take the medicine – and can’t sleep because of joint pain.

After talking for a while, we got on the bus for a physical exam – “Occupying” one of the curtained exam “rooms.” A careful history and physical indicated the belly pain was probably not a cancer or a blockage; straining made it worse… a hernia. The blood pressure recheck, resting and lying down, showed it really was through the roof. We talked about improving it; and how to safely handle joint and muscle pain at home; and how to start the process of finding a surgeon (without insurance or money), while preventing the hernia from getting much worse, given the circumstances (a new job with heavy lifting) – and, with tears and sniffles, how to adjust to the loss of someone very dearly loved – given the circumstances.

“How can I help you?”

An “eye infection,” “caused by drinking alcohol” – lasting “for the last year.” It really looked more like an allergic problem, in both eyes. Dizzy spells: a while back, the emergency room prescribed a diabetes medication that drops your blood sugar, but they weren’t eating regular meals, and, as I said, drinking a lot. Not taking their blood pressure medicine…  I hunted down the pharmacist, who was stocking the back room with vitamins and over-the-counter remedies. I ended up writing a prescription for antihistamine eyedrops, which are expensive – don’t know if we can get the charities to cover it, though. We bagged up a bottle of sterile water and an eye cup, with written instructions. See you next week for a recheck.

Eight minutes and fifty-three seconds, or twelve at best, aren’t long enough to give somebody a set of guideposts to keep chronic or recurrent problems from becoming severe.

Removing one set of ingrown stitches from one elderly patient’s eyelid took a long time. Why didn’t they go back to the hospital to get them removed weeks ago? “Nobody told me to.” Convincing another to seek out an AA meeting – and to keep going, every day – to help with intolerable loneliness (“I just can’t take it anymore”) and depression (“self-medicated”, unsuccessfully, with heavy drinking) – that took another long time. Trying to help people figure out how to get the specialist consultation their condition required – when they didn’t have any money, but weren’t yet sick enough to go to the emergency room – when I don’t WANT them to get sick enough to go to the emergency room – twelve minutes, eight minutes and fifty-three seconds? Really?

My new motto is, “Two hours ain’t bad!” Because I want my colleagues to come on down and help out for two hours a month.

There are 732 hours in a month. If, like most doctors, you work 50 hours a week, that’s about 225 hours a month. This month, there were 192 weekend hours. You probably spent about 60 of them asleep. Two hours ain’t bad! If five more doctors or FMNPs would donate just two hours a month, then our current three doctors could cut back to two hours a month, too. However, we’d be thankful to just have two more practitioners. They could just put in two hours a month; we’d keep doing four, but all the shifts would be filled; all the patients could be seen.

So much strategizing.

Sometimes it seems like a wonderful and grand experiment: what would it look like if we really regarded health care as a human right? What if people with skills just dug in and started providing it? To me, it’s a simple matter of social justice, most of the time. I remember when I was a young mom with three kids on Medicaid and couldn’t find them a doctor when I needed one, and I remember clearly how it was out of the question that *I* could have a doctor myself, without any “coverage” or cash. I just tolerated sickness as best I could. So the social justice idea is pretty visceral for me.

But then I actually get on the bus, and now the problems are even more visceral. How can you manage your blood sugars when you are living outside? How can you heal up that tendititis, that fractured scaphoid bone, when the only job you could find was grunt labor with constant heavy lifting? You stupidly got mixed up in IV drug abuse, which was a bad mistake, but you also missed the lecture about why safe sex is important and how to keep from getting pregnant – what will become of you? You’re injured, but the water company turned off your water. How will you keep that wound clean? I was vocally frightened by your bright yellow eyes and swollen belly, and I talked you into going to the special “homeless clinic” for labwork – and they put you on a two-month waiting list. Every single thing about health is about money, unless you stumble across our clinic bus.

I go home from the bus both tired and inspired, after this FOUR hour day, a traffic flow so unexpected but so crucial. I can’t help but be a little apprehensive about the challenges to come… Winter is coming. Bronchitis and pneumonia and “boot rot,” and all the messed-up blood sugars and blood pressures and everything else that goes along with people being under-cared-for, “under-covered” in the winter – they’re coming.

*Details have been altered to protect identity, but reflect real peoples’ complex situations.

OM Clinic Report – 10/28/12

The temperature is dropping and our patient load is increasing. We, at Occupy Medical (OM), are used to saying that 20 patients is about the maximum amount of patients that we can reasonably treat in one 4 hour day.
We have been refining the flow of patients through the bus both to help the patients more effectively and to better utilize our talented team of volunteers. Our new system was immediately put to the test this Sunday.
We had 27 patients. Our volunteers were literally sweating to keep up. The patients were happy. The passers-by were impressed. The volunteers were hopping.
We could not have done this a few weeks ago. One of the big changes was redefining the nurse’s station. They are still an underutilized crew but with Karen’s direction, they will be humming like bees soon.
Another change is use of the bus itself. Adrienne, our noble dental hygienist. was still recovering from OM’s free dental extraction clinic so she took the day off. We put the wound care clinic in that spot. We also started patient flow at the beginning of the bus and allowed it to ripple through to the back.
OM volunteers like to be busy. They got their wish. As winter approaches, I expect our patient load to increase even more.
Tuck in, kids. We got a long ride ahead.
– Sue Sierralupe, OM Clinic Manager