Clinical, Evidence-Based Medicine, Featured, Health Policy, Internal Medicine, Palliative Care
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Home Visit

A smear of what I assumed was cat poop obstructed a narrow asphalt path that led to a mobile home. It was raining. I tiptoed around the sopping heap of excrement, steadying myself on the vinyl siding of the trailer to keep from slipping on my way up a wheelchair ramp to the front door. Behind me, the wound care attending physician followed. I hoped she was minding the poop.

I lifted my fist to knock, but the door was already swinging open. A waft of stale cigarette smoke enveloped an old woman’s bony frame; my nostrils detected a trace of something putrid like a dead skunk. “You guys are early!” She prodded us inside, the three of us shimmying past each other in the cramped entryway while exchanging introductions. She was Donna, the “aide-turned-wife.” I was Anna, “the intern.” There was Fay, “the wound care doctor.” We found just enough space free of cigarette butts on a small cabinet and set our coats down. “He’s right in here! Come on!”

One step further into the trailer took us into the bedroom of our patient. Floor-to-ceiling shelves stacked with drug bottles and wound care supplies stood against three of the four pale blue walls. Against the fourth wall was a hospital bed and two overbed tables. We piled in around the bed, whose occupant gleamed at us with a nearly edentulous smile. This was Bud, “the patient.” Donna darted to the head of the bed and snatched a bowl of cereal from his hands. “He was just having breakfast! I’ll put this in the fridge!” Each exclamation ended in progressively higher pitched upward inflections. She slipped past us and was barely out of sight before bursting back into the room. “Excuse me! Pardon me!” Her hands batted at us, as if shooing at pests.

Donna whizzed around the crowded room, showing us Bud’s medications. In one bin, there was melatonin for sleep, echinacea for the immune system, vitamin D and calcium for bone health, and sertraline for depression. In another bin were creams, oils, gels, ointments. One bin was packed with 10-milliliter saline syringes. Drawers were stuffed with gauze, tape and Tegaderm. “I just got everything refilled last week!” His power mobility scooter fit precisely between a large shelf and the doorway — not an inch of space was spared. I scanned the shelves and found neatly labeled and organized bins. The dread I had initially felt surrounded by clutter and chaos eventually gave way to appreciation because it seemed that (almost) everything had its place and, importantly, its purpose. Surely even the stuffed animal monkey dressed as Woody from Toy Story had a purpose.

“Excuse me! Pardon me!” Donna’s hands picked at the tape that secured the gauze around his sore-riddled legs while Bud told pertinent parts of his medical history. He was a paraplegic for the past 10 years after a car accident. Donna had been his aide since that time, and they had just gotten married. He had unusual open wounds from his ankles to knees for over three years, and they were only getting worse — wider, deeper, bloodier. No skin biopsies had been revealing as to the etiology, and he had tried all topical medicines his family care provider could offer. His severely limited mobility made visits to the clinic problematic, and the quality of his non-healing wounds now demanded assessment by an expert in wound care.

Fay carefully examined the wounds. Aware of my vasovagal tendencies and intent on staying upright, my eyes were only half-focused on the bloody, weeping legs. I mostly stared blankly at the floor. Avoiding syncope was made easier by the persistent cloud of cigarette smoke that blurred the gory scene, but a glimmer of light caught my gaze. It came from his gaping mouth, revealing a crown on one of his few remaining teeth. It was a smile directed at Donna as she looked adoringly at a bright red clot dangling from a wound. She grabbed a handheld mirror that was smudged with medical-grade honey and held it behind his calf to show us the congealing blood. “Look here!” She pulled at the clot with gauze, then pointed at the amber colored glob on the mirror. “Oh, that’s just honey!” The cat licked it. Ultimately, the wounds were dressed, medications were adjusted and follow up visits were scheduled.

To be frank, I found it all to be unsettling — the cigarette smoke, the cat poop, the clutter, the ever-whizzing wife. Because internal medicine residents like myself spend the majority of training on inpatient rotations, I and many of my resident colleagues are naïve to the realities of patients and their imperfect lives outside of the sterility of clinics and hospitals. After this home visit, I realized a wealth of knowledge can be gained from bearing witness to patients’ daily lives.

Besides granting practitioners visual, audible and — dare I mention — olfactory evidence of how patients live, studies have shown that home visits reduce mortality and admission to hospitals and nursing homes among older people. This will only become more apparent and imperative with the aging baby boomer population. Home visits also improve the quality of life of home-bound patients and their caregivers, an aspect of importance to me as an aspiring palliative care physician.

Unfortunately, just as barriers exist for physically immobile or financially home-bound patients to get to clinics, so do barriers exist for insurance-bound providers to give care to patients in their homes. A systematic review of primary care practitioners’ attitudes toward house calls found that providers see home visits as an obligation that enhances assessment of patients and treatment compliance. On the other hand, they experience unsatisfactory reimbursement for house calls that renders it not cost-effective.  However, the landscape of home visits is hopefully changing as more emphasis is placed on value-based services.

Donna and Bud were doing their best with what they had, as evidenced by Donna’s meticulous attention to the details of Bud’s wounds and her exemplary organization of medications and supplies. They certainly faced socioeconomic and physical barriers that necessitated this home visit. Hopefully, our visit decreased the likelihood of admissions for wound complications such as infection while increasing Bud and Donna’s quality of life by avoiding a long day of difficult and expensive transportation. With increasing emphasis on value-based service and advances in technology, providers will be able to provide excellent care to patients like Bud that decreases cost and increases the quality of life for all involved.

Author’s note: All names and identifying information have been changed to protect patient privacy.

Image credit: room by Dean Hochman is licensed under CC BY 2.0.

Anna Stecher, MD Anna Stecher, MD (3 Posts)

Peer Reviewer Emeritus

University of Wisconsin

Anna is a fellow in Hospice and Palliative Medicine in Madison, WI. She spends a significant amount of time cuddling her three geriatric rat terriers while reading books or watching the next big TV drama.