Episode 30 - Street Medicine

Episode 30: Street Medicine Basics

The sun rises over the San Joaquin Valley, California, today is October 2nd, 2020.

I have two sneaky children who are always trying to hide during the week to play video games. Well, I read an article that gave some relief to my worried mind about the benefits of videogames. The article was published in 2007, titled “The Impact of Video Games on Training Surgeons in the 21st Century”. 

The study consisted in having 33 participants (residents and attendings) to answer a questionnaire, go through a training called Top Gun, and play over-the-counter video games. Then the doctors were evaluated in their performance during laparoscopic procedures. The results showed that video game play correlated with 37% fewer errors and 27% faster completion. Conclusion, video game experience skill correlates with laparoscopic surgical skills. Who would have thought that video games may be a practical teaching tool to train surgeons[1]. 

“Dementia is one of the greatest challenges in healthcare,” said Andrea Pfifer, CEO of AC Immune, a company developing several treatments for Alzheimer’s Disease. There is a new case of dementia every 3 seconds in the world, currently 50 million people live with dementia, and we still don’t have an effective treatment or cure. The main theory of the pathophysiology of Alzheimer’s is the accumulation of beta amyloid in the brain, but anti-beta amyloid therapies have fallen short in clinical trials, making some researchers reconsider this hypothesis[2]. 

Some underrated targets may include inflammation and vascular factors. But the tau protein, a key element in the formation of neurofibrillary tangles in the brain, is experiencing a starring moment. Semorinemab is the first anti-tau therapy to enter a phase 2 study. Alzhemier’s disease as a multifactorial condition, may need a combination of treatments with anti-beta amyloid and anti-tau medications, among other therapies. We will continue to hope for a cure as the research continues to evolve in the following years.  

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. 

“I am only one, but still I am one. I cannot do everything, but still I can do something, and because I cannot do everything I will not refuse to do something that I can do.”

– Edward Everett Hale (frequently attributed to Helen Keller)

You are only one, but you can do something for someone. This quote is very appropriate for our episode today, and you’ll see later why. This quote reminds me of the story of the starfish thrower[3], and I have to admit that I had an impulsive purchase a few minutes ago, because that story connected me to my youth, and I want to read it again, so I just bought the book in Amazon. The story is about a man who throws sea stars back to the sea to prevent their death. Even though there are thousands of stars, that man decides to change the destiny of one star at the time. We may be only one, and we may save only one star, but for that star you make a difference. I recommend you read that story. It’s inspiring. Talking about inspiring, I had a conversation with Dr Beare about street medicine, I hope you enjoy it.

Arreaza: We have Dr. Beare with us – He’s famous around here, loved my residents and staff, thank you for your time, Dr. Beare, Chief Resident Rio Bravo Class of 2019.

Beare: Thank you for the invite and kind introduction, I am Matthew Beare, Medical Director of Special Populations at CSV, development and implementation of special programs for homeless, migrant farm workers, and patients who suffer from substance use disorder. Street medicine program, branch of our homeless help, has been in place for one year. It opened in October 2019. 

Arreaza: Ok so you are doing street medicine, and addiction medicine, and primary care.

Beare: Yes, and often there is overlap between the two.

Definition of street medicine

Arreaza: What is street medicine?

Beare: From a medical standpoint, street medicine is basic medicine; more of a philosophical approach, and I guess there’s a practical difference as well, but what we are trying to do is provide high level primary care to our homeless, chronically-unsheltered patients, to meet them where they are, as opposed to have them meet in clinic.

Our philosophy of street medicine is “ go to the people,” so once a week, every Thursday, we pack up our medical supplies and a small team of us go directly into a variety of homeless encampments here in Kern County, in Bakersfield, and we provide care on site, so that can be everything from preventative care to acute treatment of different illnesses including procedures such as I&D of abscesses, joint injections, we can provide on-site prescription medications, and we can also start the process of starting lab work, sending prescription information to various pharmacies. From a medical standpoint, it’s a high level primary care, but it’s rather the philosophical approach of going to the patient versus having them come to you.

Training needed for street medicine

Arreaza: How did you get started in Street Medicine? Any special training? Motivation? Offered a position?

Beare: I got offered position of medical director and I was doing more research on homeless populations and how to better serve them. I was at a conference in Washington DC where I learned about street medicine. I learned about the philosophical approach and felt it was something missing in our community. 

When I started, I kept making plans like, “I need to go out, we need to start this team,” and eventually it got so bogged down in preparing to go out that we never went out, so finally in October 2019 we said, “forget it, were just going to go out, do what we think is best,” so we just went out, started seeing patients in variety of encampments, and since then we have been molding it to document it better and to make sure we are providing the highest level of care that we can. But there is no official title in it, to date. There is one fellowship in Pittsburgh, in Street Medicine, which is the first of its kind, so anyone interested in becoming an “official” Street Medicine provider can look into that fellowship. 

What you do in a street medicine visit

Arreaza: You’re doing this on Thursday mornings, can you describe to us what exactly you do?

Beare: We take two vehicles, we do it at 6:30 AM because it gets so hot by mid-afternoon. We have medical backpacks with a myriad of supplies, gauzes, bandages, kits for I&D, kits for joint injections, prescription medications that we work with a special pharmacy so we can prescribe those on site, and we also bring some harm reduction materials such as clean syringes, sharps disposal containers to distribute, condoms, hygiene kits, we try to bring with us essentials such as food, water, sometimes clothing, blankets. You don’t bring food and blankets to patients in clinic, and it is a crucial need so we are trying to fill that need. 

We travel to our campsites, right now we are covering a couple mile stretch between N. Chester and 24th St, there’s a riverbed that flows along there. We have covered that homeless encampment site over the last 6 months. We park our trucks, and walk along the riverbed. A lot of them are wooded areas or clandestine, so you can’t really see them. And we have been fortunate enough to establish good relationships with these patients so they actually allow us into their campsites and sometimes directly into their tents, it’s pretty rewarding in that regard. 

A street medicine team

Arreaza: What support staff do you have? A nurse?

Beare: Street medicine teams across the US are all different, there are about over 180 teams acting across the world right now, and they can all vary in how they are composed. Our team is myself as the medical provider, I have my Medical Assistant who keeps track of everything we are doing, the medications we are giving, and takes notes. We have two outreach workers with us who help the patients talk to housing authority, or if they need to get their driver’s license or social security card, they coordinate all those social aspects, and we have our homeless liaison, who maybe the most important person on the team, who has an extended experience in homelessness or substance abuse who acts as our go-between, who can communicate effectively and teach us the culture of the encampment so we don’t overstep our bounds, and then we have with us often residents and students who come along for education.

Street medicine funding

Arreaza: How does this get funded?

Beare: California right now has very strange laws on where you can and cannot see patients, so it’s difficult to bill for visits that are outside of the four walls of a clinic, and we are actively  working to change that legislation; we are working with CPCA and DHCS to get that changed, but now, our ability to bill, which is how we have any revenue for this, comes from our mobile unit, the giant RV that we go and take with us. We have very little interaction in the mobile unit itself; it’s there in case we need something, but really its parked there in case we need to use it, or for billing purposes.

Patients seen in street medicine rounds

Arreaza: Who can be seen by you? Can anyone be seen by you or it must be a specific population?

Beare: When I am on the street there is no consideration given for your legal status, or your insurance status, if you are someone who is unsheltered and you need help, it is our duty to provide that care. Anyone can be seen when we are doing these street medicine rounds. We see the same patients over and over since we are in the same area, but given the transient nature of these patients we often see new patients and, again, whether they are insured, whether they have legal status as a citizen, it means nothing to us, it is the same level of treatment. 

Arreaza: And you provide vaccines?

Beare: Yes, we do. Every year we are fortunate enough that the Department of Public Health gives us a certain number of influenza vaccines that we can give out. Last year we gave out about 100. If someone needs a specific vaccine outside of their annual flu vaccine, we can bring that out with us in an appropriately cooled container and administer it. And it’s not just vaccines, we give on site injections of Ceftriaxone, we give other on site treatment plans as well, preventative vaccinations and preventative care.

Documentation of street medicine encounters

Arreaza: And documentation, is it just like a normal visit?

Beare: Yes, it is like a normal clinic visit, and we do that intentionally as we are submitting these for billing, so we try to follow the same standards as with any other patient. We are currently undertaking some research in this community, so some of the documentation is written in a way for us to pull information from those charts, otherwise the documentation is just like any other patient, and if you read the medical record, you might not know this is a street medicine patient, unless you read “this is a street medicine patient.”

A word of advice: Just do it

Arreaza: That’s great Dr. Beare so if there is someone listening to this episode and considering being a street medicine doctor, what are some suggestions or advice you can give to them?

Beare: One of the biggest hiccups I saw when I first started, there was so much time spent in preparing, because it is such a unique way to treat the patients there is a tendency to want to do it perfectly. I could have done research for months or years on how to build the perfect street medicine team, but the only reason the team exists now is because we just went out and did it. I think that’s what it takes because if this is something you are considering implementing into your practice or career, just do it, start it, and make it perfect later, start it first. No one is reinventing the wheel here, there is a street medicine institute, so if anyone needs guidance on how this works, they can reach out or to me directly, I am happy to discuss Street Medicine with anyone who is interested (email: [email protected], work phone: 661-328-4283).

Safety in street medicine

Arreaza: Have you ever felt that your safety is in jeopardy when you go out and do street medicine?

Beare: I’m glad you brought that up. That is probably the number one concern. When you talk to people who have never experienced or seen street medicine, always the first question is “was it safe, was it dangerous?” Let me just start out, again, with the near 200 street medicine teams, to date, there has not been one reported incident of violence against a street medicine provider, I don’t think the same can be said even about clinic visits, and you’re talking about 200 street medicine teams across the world, not just in California, not just in the US, spanning across every continent, except Antarctica, there are street medicine teams and still there has not been one reported case of violence against a street medicine provider. No, I have never felt like my safety was in jeopardy nor was the safety of my team in jeopardy certainly not by any of our patients. However, you are providing medicine in the elements, and the elements can be brutal especially in an environment like this, so you have to be careful to not get dehydrated, you have to wear sunscreen and stuff like that. And we have had some issues with dogs, but you know we haven’t had, no one’s ever been bit, in my street medicine team. So, if you were at all concerned with safety, it’d be the dogs in the area.

PPE in street medicine

Arreaza: In these times of pandemic what PPE do you use? Gloves? Masks?

Beare: When we travel we constantly use our surgical mask, and if we are going to any type of COVID testing, we don the full PPE with the gown, the gloves, the N95 with the face shield, the same precautions we use in clinic, nothing too out of the ordinary. For whatever reason, COVID-19 hasn’t affected our homeless population anywhere near what we thought, it’s affected them significantly less than the general population, and there’s some hypothesis as to why that is, and in our experience, in my anecdotal experience, COVID is less common in our patients.

Patient-provider relationships

Arreaza: Any anecdotes you would like to share, anything you saw, any crazy procedures?

Beare: Crazy is sort of the norm when we go out. We see a lot of stuff that is surreal sometimes. I think if I wanted to share something about the patients we see or any particular patient, it’s the warmth of which our service is received. 

The relationships we have built are so profound, we are talking about a population that feels like the whole system has turned their back on them, from healthcare to friends, family, and the community at large has turned their backs on them, and so to get to be that ambassador of the people who genuinely care for you and you deserve the same level of care as anyone in our community, that garners an incredibly rewarding relationship. From a medical perspective, we have been able to treat so many people for chronic illness that they haven’t been treated for years. Dr. Franco, our infectious disease specialist, probably has a huge uptick in treatment for Hepatitis C cases because we have connected these patients to healthcare for the first time in years.

We have been able to avoid utilization of emergency rooms because we are managing so many acute infections in the field that these patients don’t need to go to the ER every time they get an abscess. It’s been incredibly a rewarding thing in ways that’s difficult to put in words. Now that I’ve done it for a year, I don’t think I could ever go back to not doing this. I don’t think I know anyone in the field who could not do street medicine once they have been exposed.

Arreaza: I feel very fortunate to have you here on our podcast today. You are giving us very valuable information, and the residents are going to appreciate this episode. Thank you because the labor you are doing is a labor of love. You have the knowledge and skills, and you are putting it into practice to help the most vulnerable members of our society.

Beare: Well I appreciate you giving me a platform to speak on as well. 

Arreaza: Dr. Beare thank you for being with us, any last words for our residents or faculty or listeners around the world?
 

Beare: If you have any interest, if this strikes a chord with you, please contact me. I will go out of my way to connect you with the right people. If you need anything regarding street medicine, I am always available.

__________________________

Speaking Medical: Mittelschmerz
by Amy Arreaza, FNP-BC (recorded by Graciela Peña, LVN)

We would like to present the winner of our prize for this week. Her name is Amy Arreaza, a family nurse practitioner in Clinica Sierra Vista, who also happens to be Dr Arreaza’s wife (the decision of the winner was unbiased and unanimous). Congratulations, Amy, enjoy your gift card. Now, let’s listen to your definition of mittelschmerz, as read by Gracie Pena.

As a woman who has experienced mittelschmerz, I can tell you that ovulation pain is no joke! In fact, severe mittelschmerz can be mistaken for appendicitis and can be included on your list of differentials for a patient presenting with Right lower quadrant or pelvic pain. In most cases, however, mittelschmerz is just an annoying or irritating pain that some women have to put up with mid cycle (hence the name mittelschmerz, German for middle pain).  Mittelschmerz is a pain more bothersome than any “pain in the neck” or “pain in the rear” that I have ever experienced. So instead of using those colloquial phrases to show my irritation, next time my husband is getting on my nerves perhaps I'll tell him “You're a big mittelschmerz!” 

____________________________

Espanish Por Favor: Absceso
by Lillian Petersen, RN

Have you heard that you can add an “o” at the end of any English word and turn it into a Spanish word? You can do just that with the Spanish word of this week. Can you guess what the word absceso means? Yes, absceso means abscess. An absceso is a collection of pus that can be located anywhere in the body. An absceso can form anywhere bacteria, fungus and other microorganisms can grow. Commonly, abscesos need an incision and drainage (I&D) if they are external, for example on the skin; and some may need needle aspiration or even surgery in the OR if they are internal. By draining it, some abscesos may get cured, but some may need antimicrobial medication for associated cellulitis, and large abscesos may need regular changes in packing to get cured. Now, you can add this word to your growing Spanish vocabulary, absceso. See you next week!

____________________________

For your Sanity: Jokes
by Tammy Hilvers, MD

Why did the driver hold his nose? His car had gas.

What kind of pliers do you use in math? Multipliers

Why did the math teacher skip the chapter about circles? They were pointless.

What was the silly chicken doing in the garden? Sitting on an eggplant.

______________________

Now we conclude our episode number 30 “Street Medicine Basics.” Dr Beare explained briefly what he does on the streets of Bakersfield. He shared his motivation, inspiration, and modus operandi. If you would like to expand on this topic, you may send us an email or contact him directly at [email protected]. Mittelschmerz means “pain in the middle”. It’s a pain experienced by some women during ovulation around mid-cycle. Congrats to Amy for her creative definition and for her . Our nurses had a special participation today, Gracie recorded the definition of mittelschmerz, and Lilli taught the word absceso, which is Spanish for abscess. What a great team we have!   

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This episode was brought to you by Hector Arreaza, Lisa Manzanares, Amy Arreaza, Gracie Pena, Lillian Petersen, and Tammy Hilvers. Audio edition: Suraj Amrutia. See you next week!

_____________________

References:

Rosser JC, Lynch PJ, Cuddihy L, Gentile DA, Klonsky J, Merrell R. The Impact of Video Games on Training Surgeons in the 21st Century. Arch Surg. 2007;142(2):181–186. doi:10.1001/archsurg.142.2.181. JAMA Network: https://jamanetwork.com/journals/jamasurgery/fullarticle/399740

Loria, Keithm, Alzheimer’s research shifting to tau as a target, Managed Healthcare Executive, September 2020, Vol. 30, No. 9, 7-8.

Loren Eiseley, The Star Thrower, New York: Harcourt, Brace, Jovanovich, 1978, pp. 171–73, 184. Quote by David B. Haight, https://www.churchofjesuschrist.org/study/general-conference/1983/10/become-a-star-thrower?lang=eng

University of Southern California, Street Medicine, https://sites.usc.edu/streetmedicine/

Street Medicine Institute, https://www.streetmedicine.org/