Hearts of the City
Nurses take their services to the commonly overlooked pockets of underprivileged communities

By Cathryn Domrose
May 12, 2004

On her way to the theater in Houston one evening, Margarita Sloan, RN, MPH, FNP, was struck by the sight of a homeless woman on a street corner. Open sores, probably a side effect of diabetes, covered the woman’s legs, Sloan said. The woman was talking to herself and obviously
mentally ill.

The homeless woman’s corner was two blocks away from the Texas Medical Center, one of the best health care facilities in the United States. But the woman might as well have lived in India, said Sloan, an independent nurse practitioner who has worked with indigent patients for nearly 20 years. “She wasn’t getting medical care.”

As Sloan and other U.S. nurses who work with the poor know, even in a land of shining health care centers and medical miracles, many people on the lowest end of the economic scale are not receiving basic health services.

To serve them, these nurses have eschewed comfortable offices, state-of-the-art operating rooms, and glass-and-steel complexes in favor of homeless camps, run-down apartment buildings, and the hallways of inner-city emergency departments.

Their miracles don’t come from research breakthroughs or new technology or amazing medications. They settle for getting an asthmatic patient to stop smoking, or an illegal immigrant hooked into the health care system, or a mentally ill homeless man to let someone wash his rotting feet.

They also advocate for their patients on a broader level, working to persuade legislatures and communities to support health care programs for poor and uninsured people. Some have worked with vulnerable populations for years; others are students who realize this work may be their calling.

All are heeding the call from the International Council of Nurses to work “side-by-side with clients, service providers, community leaders, policy makers and politicians” to “reduce the plague of poverty.”

Spokane: Helping the homeless

In the common room of the House of Charity, a homeless shelter in Spokane, Wash., nursing student Sachiko Yakashiro noticed an elderly man who wore slippers instead of shoes. When she and other students tried to get him to take off the slippers so they could examine his feet, he refused, saying the smell was too awful.

Foot problems are a common condition among the homeless, said Carol Allen, RN, PhD, a senior instructor at the Intercollegiate College of Nursing/Washington State University College of Nursing in Spokane. The homeless spend a lot of time on their feet, she said. They often have terrible shoes and no places to change their socks — if they have socks to change into. Some may have fungal problems, others may have disabilities that preclude proper care for their feet.

As part of their clinical work in community and psychiatric health, WSU nursing students like Yakashiro visit homeless shelters, homeless camps, and low-income housing complexes to help bring health care to those who can’t afford it or won’t seek it.

Allen, who has worked in Micronesia and with low-income African-American communities in Southern California, accompanies the students as they offer health education, care for wounds, take blood pressures, and listen to people’s stories.

Health problems among the homeless and poor usually are complicated, Allen said. Many patients are mentally ill and won’t take medications because they don’t like the side effects or the way medications make them feel. Many are addicted to drugs or alcohol and not ready to seek treatment for their addictions, but need medical care for conditions such as abscesses caused by skin-popping methamphetamines and other drugs.

At first, Yakashiro thought the best way to help the man in the homeless shelter was simply to listen to him. She discovered he lived in a small car and slept sitting up. He spent most of his days in the library, researching his family’s genealogy. She knew he was mentally ill, but he didn’t want to talk about his illness.

“I was trying to build up his trust,” she said. Finally, he took off his slippers and showed her his feet. They were puffy, bleeding, cracked, and weeping. He had venous and arterial insufficiency, accompanied by severe edema. She soaked his feet in water and tried to massage them, but that was too painful, she said. So she kept soaking them and removed as much dead skin as she could. She also showed him how to care for his feet on his own.

Her treatments, coupled with medication, started to work.

After three weeks, the swelling subsided, the color became more normal, fluid stopped seeping out.

“I had no problem with the feet and the smell,” Yakashiro said. “It made me think that I want to go into this field later. I really like working with this population. I found no difference between the people in the shelter and me and my friends.”

Yakashiro will graduate in May. She has finished her work in the shelter and misses her patient, who told her she was the fourth person in his 71 years who had influenced his life deeply. “I’m really happy that I had the chance to meet him,” she said, “because he taught me a lot of things, too.”

Oakland: On the frontlines

Outside the Highland Hospital emergency department in Oakland, Calif., the sun is shining and a gentle breeze wafts through the hills. Along the long hallway of the emergency department, a few patients sit on beds. A few others receive treatment in rooms, but many areas — the trauma center, the orthopedic area — are empty.

“It’s a very slow day,” said Anita Walton, RN, an ED staff nurse who has worked at Alameda County Medical Center for 16 years, including 10 in the emergency department. She smiled. “I think it’s the weather. No one wants to be in a hospital on a day like this.”

It’s also a rare day for the emergency department, which is expected to treat about 80,000 patients this year, up from an average of 70,000 in previous years. Like most county facilities, the Alameda County Medical Center is the main health care provider for the poor and uninsured. Alameda ranks 46th out of 58 counties in California in poverty and is the poorest county in the San Francisco Bay Area. The area’s unemployment rate more than doubled in 2002, and many have lost their health insurance as well as their jobs.

But anyone who arrives at Highland, no matter where they come from, “receives very good care,” Walton said. “We’re here to serve the community, so no one gets turned away.”

Walton has seen patients who come in once a year or once a day. She sees people far from home and people who live a block away. She sees homeless people who admit straight out that they don’t need medical care — just food or a place to sleep. She sees substance abusers, victims of domestic abuse, the mentally ill, people newly diagnosed with chronic illnesses such as hypertension or diabetes, and people in late stages of illness who need dialysis or other treatment.

ED nurses are sometimes the first service providers on the line, Walton said. Nurses often provide referrals, track down social service agencies, call shelters, and give hungry people something to eat. It’s all part of working for a county hospital, Walton said. “Everybody in the hospital does a little more than what their designated role is.”

The best part of her job, Walton said, is patient education. Most of her patients have never had anyone talk to them about eating more fruits and vegetables or lowering their salt intake. Recently, she saw an asthmatic patient with whom she had had a long talk on the dangers of cigarette smoke. “Thank you for that talk,” the patient told her, “because I’ve stopped smoking.”

“That made me feel really good,” Walton said.

Walton is working to ready a new ED facility that will offer more patient privacy than the long hallway of the old building. It’s important work, she said, but she misses her time with patients.

Despite enough experience to get a job practically anywhere in a state desperate for nurses, Walton has no plans to leave the Alameda County Health Department. She lives about two miles from the hospital and considers herself part of the community it serves. She eventually may work in community health, doing home visits, she said, but believes she will always work with and advocate for the poor.

“I like working here,” she said. “I wouldn’t have stayed this long if I didn’t. This place can get stressful, but I think the [veteran] nurses are so used to crisis management that it’s like putting your clothes on in the morning.”

Houston: Caring for immigrants

On a typical day in her office, Margarita Sloan’s first patient was a 7-year-old girl with a dead cockroach lodged in her ear. The roach was stuck in so far that Sloan couldn’t get it out, even after irrigating the ear. She gave the girl drops to ease the pain and loosen things up so she could try again the next day.

The problem was not unusual, given the girl’s vermin-infested environment, Sloan said. Children in her neighborhood often have health care problems caused by roaches, mold, and poor ventilation. She constantly sees kids with runny noses and ear infections that are caused by the environment instead of viruses.

Sloan’s office is in a low-income apartment complex on the western edge of Houston. Through a program sponsored by the University of Texas Health Science Center at Houston, she treats her patients without charge or questions about documentation. Many live in the apartment complex and surrounding neighborhood, but some come from 15 or 20 miles away. Most are new immigrants from Central America and Mexico. Many are not in the United States legally.

Sloan sees about 15 patients a day and works with one assistant, a community outreach worker who helps with paperwork. She thinks it’s important to have a strong presence in the community she is serving. “The only thing I don’t do there is sleep,” she said. She is originally from El Salvador, a country with vast poverty and not many services. She has always been drawn to “people who need services and can’t get them anywhere else,” she said. “That’s where I see the role for nurse practitioners, to work with these people.”

The children she sees at least receive regular medical care, she said, although often in the emergency department of a community hospital. But many adults do not seek care until they become very ill because they are afraid hospitals and clinics will ask about their immigration status, she said. She commonly sees patients who have not been to a doctor for more than 10 years.

An important part of her work, Sloan said, is getting people hooked into the county health system, which requires photo identification, obtained from their consulate if necessary, but not documentation of immigration status. But many people don’t understand the difference, she said, and don’t seek care at all, sometimes with fatal consequences.

One patient, a man in his early 40s from Mexico, came to her office barely able to breathe. He lived in an apartment with three other immigrant workers, and had no family in the United States. She took him to the emergency department where he was diagnosed with congestive heart failure. His daughter from Mexico came to see him, but he eventually died in the hospital, she said.

Another time, a woman brought her 18-year-old son to Sloan. The young man was hallucinating and hearing voices. His mother had kept him in her house, watching him night and day so he wouldn’t run away. She was terrified to take him to a hospital because she had no papers and didn’t know what to do.

Sloan convinced the mother that her son needed treatment for mental illness and drove them to the emergency room. This time, the patient was treated in time. He was given medications and an appointment to an outpatient clinic. The next time Sloan saw him, he was talking normally and his mother said he was sleeping through the night.

“You can make a difference in the lives of some people,” Sloan said. “The rewards are just amazing.” So are the frustrations. “In a day, I can see one person that could get me depressed. But I don’t really get depressed. I feel like, how do I deal with this person now? So it’s more of a challenge. You just have to do it.

“These people don’t have anybody else.”

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