“The poor are sick and need medical attention, but also a helping hand and

welcoming smile.”

Mother Teresa

“Clinic” was about two blocks down the street from the hospital, in a low single-story building badly in need of repair. Twice a week, usually around noon, the general surgery residents ran a free clinic. We provided free surgical evaluation and care to those who had no insurance and no means to pay the high cost of medical care.  One senior resident was in charge, with an intern and medical students helping. The clinic was the clearest reminder of the hospital’s original mission. St. Mary’s Hospital had been founded by nuns and had a long tradition of caring for the community’s underserved. The nuns still held influential roles in administration, helping ensure the hospital never lost sight of that mission. Although the hospital had changed over the years in its effort to stay financially stable, its commitment to caring for the poor and vulnerable remained alive and well in the clinic. It was alive, anyways. I don’t know how “well” it was.

     I met one of my chronic problem patients at my very first Clinic.  His name was Frederick LaFountaine III, a very distinguished sounding name for such a profoundly un-distinguished man.  He became an inexhaustible source of amusement and annoyance to me for the next six years.  Freddie had been admitted to the hospital about two weeks ago, discharged to jail, and was here for follow-up care.  He was a shifty little guy about thirty-two years old, with eyes that bulged out a bit and a big gap between his front teeth.  The medical problem that landed him in the hospital was a big infected wound of his left hip.  He had been smoking, drinking, and abusing heroin for about as long as he could remember.  He dabbled in all sorts of other drugs but always came back to his tried and true favorite, heroin.  He claimed to have a series of odd jobs, but had been fired from most, or just decided to stop showing up, as work tended to interfere with his social habits. 

     His story, which differed significantly from the police account, was that he and a buddy were hanging around outside a warehouse at two am, minding their own business, when they heard a puppy trapped inside.  They decided to try to break in to save the puppy.   Luckily, they just happened to have a nice supply of tools perfect for breaking and entering with them.  He fell through the roof and landed on high stacks of cardboard boxes, then it looked as if he had crawled down, laying down on the concrete floor about twenty feet from the hole in the roof, where he promptly passed out.  He remained there unconscious for about forty-eight hours, when the Monday morning shift came to work and found him.  It seems his good friend took off as soon as the roof collapsed.  And there was no puppy anywhere. 

     The weight of his own body, not moving for that long, had caused full-thickness skin necrosis of a six-inch area of his left hip, which progressed to a gangrenous infected wound.  His alcohol level was still high when he arrived at the hospital, and his tox screen revealed about three other illicit substances.  The patient had claimed initially that he had suffered a major head injury from the fall, but no evidence of any brain or skull injury had been found.  Then he claimed the trauma of falling through the roof had triggered seizures, which is why he ended up passed out there for two days.  He had no history of seizures, and he didn’t really understand that seizures generally don’t result in altered consciousness for two days straight.  But that was his story.  And it had all been to save the poor trapped puppy they heard in there.  The police figured he and his buddy, drunk and high on something, planned to break in and steal things to sell for drug money.  He had about ten prior convictions for this sort of thing.  Once inside, he basically lapsed into a drug-induced coma, until he was found on that Monday.  He’s quite lucky he didn’t just stop breathing and die or go into complete renal failure.      

     Anyway, he had found himself a lawyer and they were looking into suing the warehouse owner for having unsafe roofing, leading to the accident that caused his hip injury.  During his hospitalization, his wound had been debrided of most of the dead tissue, leaving a big eight-inch gaping wound, open nearly down to the bone.  This was going to take weeks of daily wound care until the infection was cleared, and some type of a big flap procedure to cover that bone and fill the soft tissue defect.  

     Freddie was accompanied by his rather freaky girlfriend.  She was painfully skinny, with long straight hair nearly obscuring her face.  She had obvious needle tracts up both forearms and appeared to be totally stoned every time I ever saw her.  She had a vacant look about her and would answer questions so slowly I sometimes wondered if she was actually alive.  They were a perfect match.  Her complete lack of any animation whatsoever nicely complimented his incessant nervousness. 

     He was out on bail, awaiting his court date.  He had failed to show up to the wound care center for the last three days and hadn’t done any sort of wound care himself.  He still had the same dressing in place that he had left the hospital with four days ago. 

“Now, why didn’t you go to the wound center?” I asked, after listening to the whole story about how he would be coming into a lot of money soon, once the warehouse case was settled.

“Well, I can’t just cut out a big chunk of my day like that.  I got some projects I’m working on.  I’m on a job now. And I can’t just always get a bus when I need it.  And I didn’t know for sure where to go.  And I don’t know what time to be there, you know, nobody told me nothing at the hospital,” he rapidly responded, shifting back and forth constantly, snapping his fingers and periodically waving his arms around.  He was always nervous and fidgety. 

“Okay, well let’s get a look at this thing.” 

     I had him lay down and started to remove the dressings.  The deeper I went through the layers of gauze, the greener they became and the stronger the stench grew.  It’s pretty hard to describe the overpowering offensive odor of an infected wound that’s been neglected for a few days.  The wound was a terrible mess, with pus puddled at the base, surrounded by soft, mushy lumps of dead yellow to green tissue.  

“Hold on, Mr. LaFountaine, I think we need to work on this a little,” I said as I quickly exited the room to find my senior resident to get a look at this.

     She took a quick look, rolled her eyes, and told me to get the medical students working on it.  She had taken care of him in the hospital, so was familiar with the whole story.

     We gathered our supplies, and I did a quick demonstration on wound debridement.  I left the students to cut and pick away the dead tissue and clean up the wound.  I quickly saw a few more patients, then popped back in to see how the students were doing.  They had done a nice job, and we bandaged him back up and sent him on his way, stressing the importance of returning daily for his wound care. 

“If this infection gets worse, it can spread to your bone, then we would need to go to the operating room and scrape some bone out, or maybe even amputate the leg.  We‘ve all seen these infections get that bad.”  The medical students nodded knowingly.

“Okay, yeah, yeah, okay.  Right on, right on.  Now the thing is, I gotta have something, cause this thing hurts like a son of a bitch, you know.  It’s just a big fuckin’ hole right in my leg.  It freaks me out.  I got some things going on, I gotta be able to move around, you know,” he replied.

  I doled out the percocet prescription, along with some antibiotic samples a drug company sales representative had left. 

“Come back next week to let us get a look at this.  And you have to go to the wound center every day.  Every single day.”   

     At times I dreaded going to the clinic.  It took me away from the OR and I couldn’t get my floor work done, it just piled up and waited until clinic was over.  But down at the clinic, I wasn’t just the intern.  To the clinic patients, I was their doctor.  They looked to me for guidance and trusted me to get them safely through their surgery.  They knew that we would be helped out by a staff surgeon, but they usually didn’t even meet that person.  I was their surgeon.  It could get very busy and hectic, but these clinic patients were the first patients who were really mine, and there was a lot of satisfaction when they came back after surgery better off than they were before.  That is one of the reasons surgery was so appealing to me.  The surgeon has the ability to make such profound changes in a person’s life, with such dramatic interventions.  With a one-hour operation, we can get rid of the daily pain someone has been having for years from a hernia or gallstones.  We can remove a worrisome lump, then assure someone they don’t have cancer.  Or if it is cancerous, we may be able to cure them with surgery.       

     I thought back to my first experience in the surgery clinic as a medical student at Ohio State.  I saw my patient and wrote out a nice, detailed two page note describing the symptoms and my exam.  I proudly presented this to the senior resident, who had three other students and an intern waiting for him.  He cut me off in mid sentence, chuckled to himself, and tore my note neatly in half.  He pointed to the afternoon schedule, which had about sixty names on it, and said “You are not on your Internal Medicine rotation anymore.  This is the Surgery Clinic.  We do not write books.  Notes are this long”.  He held up his thumb and finger, indicating a length of about two inches.  “We don’t have time for books.”  As I worked my way through dozens of my own clinic patients, I came to understand exactly how he felt.