Street medicine's hard choices

In January 2007, I started treating homeless patients on the streets of Santa Monica. I met Michael during the first few weeks. The first time I met him, he had all his belongings skillfully balanced on his bicycle. He seemed shy but pleasant. With a smile, he said, "No, thank you," to my offer of medical help and avoided looking me in the eye. The next time I saw him, he asked one of the medical students who joined us in our outreach efforts for something to treat a rash.

Seeing that my previously spurned efforts were now welcome, I gave Michael (medical privacy rules don't allow me to use his full name) an antifungal cream, which made me feel as if he had just agreed to lifesaving cancer treatment. The next week, he said the cream didn't work, so I arranged for the care and supervision of his heavily laden bicycle and took him to the clinic for a proper examination and treatment. He was seen, treated and referred to a specialist.

Not many people know much about street medicine, in which healthcare providers go to where the homeless are, rather than waiting for them to come to our offices and emergency rooms. The practice began in the 1980s when the homeless population began to explode and primary-care physicians realized that the homeless population was extremely ill, failing to receive appropriate care, relying heavily on emergency room care and dying at an alarming rate.

The way it works is that I go in a van with other outreach workers to find homeless people under the pier, in the parks, on the Promenade, in the alleys, on the beach. I walk with my backpack filled with medications and supplies, a clipboard and a stethoscope, asking homeless people if they need medical attention. I've taken out sutures, removed staples, cleaned wounds, treated bronchitis, diagnosed diabetes and brought patients to the clinic or to the emergency room.

According to the most recent information provided by the Los Angeles Housing Service Assn.(current as of October), about 73,000 homeless people seek shelter or are on the streets on any given night in Los Angeles County. There are fewer than 13,000 shelter beds in the county, so more than 60,000 people live in the streets. Twenty-five percent are part of a homeless family, 15% are under the age of 18, and according to a study by the nonprofit group Shelter Partnership, there are from 3,000 to 4,000 homeless people older than 62 in L.A. County.