ER in an RV

It’s been a week, and the swelling’s gone down. But the thing is still really painful.

It’s right here, she says, reaching around to the small of her back and pulling down the waistband of her pants to expose the warm, red inflammation on her right hip.

The swelling’s gone down now, but a couple of days ago this throbbing pocket of pus and bacteria under Denise’s skin was 8 inches across. The pain is why she is sitting here on a Saturday afternoon, outside an aging RV parked beside a West Sacramento church, waiting for her name to be called.

Denise is also here because she knows this can be serious, abscesses. Injection-drug users get them when they miss the vein, or when they use dull or dirty needles and a bit of bacteria gets under the skin. One time, an abscess on her chest became infected with a flesh-eating disease. Ripped away a chunk of her left breast. That’s the only way to kill that stuff—cut it out and don’t be conservative.

Denise, 44 years old and a grandmother, had kicked heroin. She had three years’ clean time, she says, sounding pissed at herself, but passively pissed, as if shrugging her shoulders at the three years gone. Several weeks ago, when she and her husband moved to a new place in Sacramento’s south area, Denise tried to meet some new people—“trying to fit in where I didn’t belong,” she says—and let a woman move into her place for a while. The woman brought along her drug habit. Now, Denise has used a handful of times in recent weeks.

She only has six months left on her parole term. And she lucked out this time around with a cool parole officer. He hasn’t tested her yet for anything. Last thing she needs now is that maybe word gets back to her parole officer that she’s been using. (That’s why SN&R is not using Denise’s last name, or those of some others in this story, because the potential consequences for them include jail time.)

The swelling’s gone down—the abscess now is about half the size it was. But damn it if she doesn’t bump it against every car door, chair or kitchen counter she comes near. Hurts every time—a dull stinging. She tries not to move, sitting here waiting her turn. It appeared about a week ago, and she knew it would because that bitch stuck her too high. Denise told her so—that it was too high. The girl pulled out the needle and stuck her in the wrong place again, squeezing the black tar underneath her flesh.

Shoulda never let that girl move in, Denise says.

But even with that flesh-eating, bacteria-under-the-skin, radiating-pain abscess experience under her belt, Denise didn’t race to the emergency room a week ago when this thing showed up. They treat you like dirt there, in the emergency room, addicts say. They say you did this to yourself and tell you there are people with real problems—real emergencies—coming in here in ambulances and on stretchers, and you just wait to get seen or maybe get told to go home and come back tomorrow to wait again.

So, addicts let their abscesses get black and swollen and tell themselves, I’ll go to the hospital when I’m dying. Denise waited. Her husband put alcohol on the abscess twice a day. The swelling went down.

A neighbor with a car—a 29-year-old friend with two weeks’ clean time of her own, who calls Denise “Mom”—had been to the mobile clinic and remembered that the people who worked there were “angels.” They tested the neighbor for hepatitis C and hooked her up with a university research study that’s providing the medicine she needs for free. She told Denise: Get in. I’m taking you there. We’re gonna go get that thing checked out and make sure it’s not something really bad. Make sure you don’t lose another chunk of your body, or maybe your life.

So, instead of sitting at the emergency room or sitting home on a weekend afternoon trying not to get high, Denise, with no medical insurance and six months left on her parole term and this abscess with this damn pain throbbing beneath the waistband, sits here, outside Community Lutheran Church off Jefferson Boulevard in West Sacramento, waiting for her turn inside this RV.

She knew it was gonna abscess when that girl stuck her too high.

The doctor
The 30-year-old, 45-foot RV manufactured by a short-lived Southern California company called King’s Highway sometimes smells like it’s overheating. The sun-worn white exterior screams for a paint job; you can tell someone else thought so, because it’s partially sanded down as if in preparation for bodywork. An old cartoon-character dog logo of some sort is still partly visible toward its rear. A water hose runs from a nearby building into the RV to supply the faucets inside, and water leaks through the frame of the RV, leaving a muddy puddle underneath. Inside, the RV is outfitted with two medical-exam rooms—one at the front, behind the driver’s seat, and another toward the rear—and a work station in between, all with low, mustard-yellow ceilings and faux-wood-paneled walls.

Peter Simpson, who runs the nonprofit Harm Reduction Services (HRS) office down in Oak Park, right there on 40th Street at 12th Avenue, found this thing at a Sacramento County auction a couple of years back. He put all $2,800 on it—everything HRS had in the bank at the time—but worried he’d be outbid, so he called the good Dr. Neil Flynn, who kicked in another grand, winning the RV.

Flynn is the man who started this medical clinic—the Joan Viteri Memorial Clinic—that targets Sacramento’s injection-drug users, those people in the community who are high in risk but low in medical-insurance coverage.

During an annual lecture to medical students over at the UC Davis School of Medicine—one of Flynn’s speeches where he talks about how drug addicts are abused in this country and in which he calls them “America’s untermenchen”— a student suggested someone go find those drug users and street workers and deliver medical treatment to them, old-fashioned house-call-style medical outreach.

Flynn, 57, works in the infectious-diseases department of UC Davis’ Medical Center in Sacramento, with AIDS mostly, conducting research and doing drug studies and vaccine trials. For nearly 20 years, he says, he has studied how to bring compassionate medical care to drug addicts. So, this student’s idea fit right in with his philosophy, which is this: Drug-prevention money is doled out backward. Eighty percent of all government funds to combat illegal drug use go toward law enforcement, he says; the remaining 20 percent to medical treatment.

“The paradigm is almost 180 degrees from where it should be,” Flynn said. “Punishing the behavior is almost the antithesis of what there needs to be.”

Doctors need to start viewing drug users as addicts, not as criminals, he says. “We, of all people, should know that addiction is not something people have control over or can be considered self-inflicted,” Flynn said. If doctors can’t get that straight, how can law enforcement and the rest of society be expected to?

But he acknowledges that bias against drug addicts was packed into his medical schooling.

“I was taught … that these are scumbags—criminals who prey on other people and that they don’t care about anybody but themselves,” said Flynn, 47. However, “when I talked to these people, they were not as we represented them in our practice and teaching.”

In 2000, the first year of the Viteri clinic, volunteer medical students from UC Davis conducted 1,000 patient visits. The clinic closed for two years and reopened in 2003 as one of six school-sponsored volunteer clinics. Neither the students nor the supervising doctor are paid for their work.

For the first time this year, the clinic went mobile, rolling to West Sacramento to reach people there. Next month, the RV will travel to North Highlands. Organizers want to reach those in Del Paso Heights and other areas. Ten to 15 patients are seen at the clinic each Saturday afternoon. Flynn said that with approximately 14,000 daily injection-drug users in Sacramento, there is enough need that the clinic could be busy a second day of the week, or for a second RV in another location.

Reaching more of the often-neglected population could save taxpayers even more money, according to Flynn and HRS. When drug injectors without medical insurance are seen at the county’s taxpayer-funded UC Davis Medical Center emergency room, the hospital eats the cost. Just to break even, the hospital spends $1,000-$1,500 for a routine visit, Flynn estimates. The Viteri clinic can provide the same service for about $200, he said.

In three years of the clinic, Flynn said, “we have seen enough successes that we know we’re on the right path.”

The namesake
In March 1997, Joan Viteri was a bright, passionate 32-year-old woman.

She was happily married and holding down a full-time job. She loved riding horses and displaying her “wonderfully wry” sense of humor, according to her cousin, Rachel Anderson.

“She had a heart as big as all outdoors,” Anderson said.

Viteri was also a heroin user. And she developed an abscess.

“She’d been a drug user for years, had abscesses, and been to ERs and been treated like crap,” Anderson said.

Anderson, who works trying to prevent the spread of HIV among Sacramento’s injection-drug users, said emergency-room doctors too often judge them for their behavior and treat them accordingly. The stories make their way throughout drug communities—doctors who don’t want to treat drug users at all; doctors who refuse to use topical anesthetics before cutting into an abscess; doctors who cut liberally, leaving large scars.

“It’s like they’re saying, ‘If this is hard enough, hurts enough, or disgusting enough, maybe you’ll stop doing this to yourself,’” Anderson said. “Or it’s just strictly done as a form of punishment.”

And so Viteri didn’t go to the hospital, even though she knew her wound was bad enough to need treatment. Her husband couldn’t convince her to go, so, four days after Viteri first noticed the abscess, he called Anderson.

“I sat with her for hours until I finally got her to go in,” Anderson said.

Turns out Viteri had contracted flesh-eating bacteria—necrotizing fasciitis.

She went into surgery to have her arm and a big chunk of her shoulder cut away, said Flynn, who cared for Viteri during her short hospital stay. During a second surgery to remove more bacteria, Viteri died.

“Her body couldn’t take it,” Anderson said. “It’s almost like somebody dying of measles today. It was a preventable death.”

Flynn said Viteri—a productive young woman “well on her way to giving up heroin”—perfectly illustrates what he is fighting against.

Anderson agreed, explaining why she and Flynn thought to name the clinic after Viteri: “I don’t care what your stance on the drug war is. I will argue to the day I die that she did not deserve to die, at age 32, for being a drug user.”

The patients
“I love my drugs,” says Caleb K., sitting with his elbows on his knees, on a bright Saturday in early April, waiting for his turn to see the doc. He’s rolling a newspaper in his two fists as if he’s holding a baseball bat.

“I started when I was 11,” he says, explaining that he grew up around older kids who turned him on to his drug of choice: a speedball of crank and heroin—“the ultimate,” he says.

He fixes three times a day. Metered. Spaced out. Not wanting to waste. Just wanting to feel and sustain his high. He doesn’t want to quit. He even chose the drugs over his family, he says, like it was a rational life decision.

Caleb’s a drug runner, he says, which means he goes out on the street, makes the buy and brings dope back for others, who pay him with cash or a portion of their buy. It’s how he supports his habit without resorting to breaking into houses or prowling cars.

Caleb’s off-and-on woman uses, too. She works the streets, he says.

He’s been coming to the Viteri clinic since it opened—he’s here today, where the RV is parked outside the HRS office, for a variety of minor maladies. Caleb’s been to emergency rooms, he says, lifting the sleeve of his white T-shirt to reveal a thick, 5-inch-long scar that cuts through a tattoo on his left shoulder. It’s brutal how they deal with abscesses there, he says.

“We’re drug addicts, so we’re low-class,” he says.

A man named Robert overhears the conversation and chimes in.

“Sometimes you sit there 12 hours, and then they tell you to go home and come back tomorrow,” he says. “When you’re coming down, feeling sick, you don’t have time for that. You have to go back out there and hustle.”

Robert, a stunned-looking younger man with a shock of telltale blond hair, came to HRS today to try to get into a drug-rehab program. He also has a bruised and swollen hand that he’ll get a doctor to look at. While hovering around the clinic for several hours, he has hustled the medical students for food, cash and cigarettes, playing off the compassion the students are learning to display. He’s coming down from his last high from the day before yesterday.

“You’re hurtin’ right now, huh?” Caleb asks him. “You know what rehab’s like? You sure you wanna do that?”

“Yeah, I want to get straight,” Robert replies. They’re talking within earshot of HRS outreach workers and the clinic’s med students.

“Well, I was gonna say, if you couldn’t get what you need, I’ll get you right,” Caleb offers.

“Ah, nah. I can hustle. I got no problem with that,” Robert says. “I want to get straight. I want to.”

Caleb pushes his sleeve back down over his abscess scar and rolls the newspaper in his hands again. “Yeah, they treat you right here.”

But why do these doctors care about addicts, Caleb is asked. What makes them different from those in the emergency room?

“They’re out here on their own time—so they must care,” Caleb says.

Later, after his visit, Caleb disappears into the Oak Park landscape of chain-link-fenced yards and convenience stores. Robert is still waiting to be ushered to a treatment facility and starts asking around: “You seen Caleb? When’s he coming back?”

The students
Sitting here sideways in a plastic chair, her legs dangled over an armrest, Agnieszka Witkowski pensively writes in a medical chart. She’s just seen a patient and has to document what the patient told her, what she observed, her assessment of the problem and a plan to address it. She’ll relay the information to the day’s attending doctor.

This is a large part of what Witkowski, 27, and the other first-year medical students learn out here on Saturdays, volunteering their time between labs and classes and finals—the practical stuff—the stuff every doctor needs to know how to do. But it’s not all she is learning.

Medical school is four years. The first two are the book years, full of classrooms and tests and dissections. Not until fourth year do aspiring doctors typically get hands-on, autonomous experience with live patients. Here, at the clinic, first-year students like Witkowski get to probe, question, begin developing a style of bedside manner, examine wounds and propose remedies, all with a doctor’s supervision and tutelage. Here, students get a glimpse of a life on the opposite end of the spectrum from which most of them grew up.

Witkowski, a San Franciscan who transplanted to Davis for school, says the drug world doesn’t shock her. “I’ve known people in that world,” she says vaguely. It’s part of why she chose to take part in this clinic—because she knew she’d be open to it and others wouldn’t.

Here’s what has been knocked into her head, repeatedly, when meeting patients at the clinic: The people who are marginalized—drug users, the unemployed, parolees, etc.—are not too far removed from herself; they’re not always the dregs it’s easy to imagine they are.

“The people who slip through the cracks and end up in our clinic are regular people,” she says. “One bad thing happens, and people you and I know are all of a sudden in our clinic.”

That’s exactly why Witkowski chose to participate in a clinic during her first year of med school—to meet patients on a one-on-one level, get to know them as individuals. And it’s exactly what Flynn wants to happen; he wants the doctors-in-training to have the same epiphany he did.

The advocates
Lois McClain remembers the date. February 16. Just four months ago. She was at home in downtown Sacramento, watching television.

That was the day McClain, 49, a former schoolteacher—mother to three of her own children and guardian to seven others—took one of life’s hard left turns.

She recently had ended a two-year relationship with a man—and hadn’t seen him in a couple of months—when he appeared on the screen. It was some sort of news story, and the man was being interviewed. Channel 10.

On the screen, the man said—actually broadcast—that he’d been HIV-positive since he was 19 years old.

He’d never told McClain.

Right then, she put on a coat and started walking. She’d heard about a place down in Oak Park, on 40th Street, where they did HIV testing, and she headed toward it.

“I walked here,” she said recently, sitting in an office in the small building that houses HRS. “I walked here and took that test.”

But she already knew what it was going to say. The next day, February 17, McClain became a volunteer at HRS, learning everything she could about the disease she’d contracted.

“I really knew nothing about it—I was stupid to the fact,” McClain said. “I thought someone could sneeze and spit on you, and you’d get infected.”

She now volunteers at the office almost daily, educating people about HIV and hepatitis C and other dangers that go along with injection-drug use. She has received a state certification to test others for HIV.

The mobile clinic’s identity is intertwined with HRS, whose frayed, shoestring budget helps keep the RV running and whose staff feeds it a stream of patients. Without HRS’s outreach workers, those who need the medical treatment offered in the RV would hardly know that it’s available. Everyone who works here at HRS, like McClain, knows of what they speak. They were drug users, or they have worked the streets, been in prison or contracted HIV. They know the community. They visit with people in drug houses and down by the river. They are charged with ferreting out those in need and connecting them to help, which includes the mobile medical clinic.

When McClain talks to community groups, she tells her story in the third person. She talks about unprotected sex, and HIV infection, and lets her audience form a picture in their minds of the person she is talking about.

“Then I say, ‘This is that face. I’m talking about myself,’” McClain said. Keep in mind that McClain is 49, professional-looking, positive-sounding and healthy. “Most people are shocked.”

Denise
It’s nearly 4 p.m. back outside the RV in West Sacramento, and Denise is next in line to see the doctor. Medical student Tina Oliver drags chairs for Denise and her husband to the base of a nearby tree and sits down next to the couple so that she can take vitals.

Denise notices the platinum engagement ring on Oliver’s left ring finger and compliments it. “Isn’t it pretty?” Denise repeats to her husband.

Oliver asks her patient why she has come to the clinic today.

“Abscess,” Denise says plainly, removing a digital thermometer from her mouth.

“Where is it?”

“Right here,” Denise says without hesitation, stretching down her waistband.

“Are you still using?” Oliver asks.

“No.”

“When was the last time?”

“Yesterday,” Denise says, exhaling quickly as if trying to work up a short, mitigating laugh.

A few moments later, inside the RV, Denise pushes herself onto an examination table, like one found in any medical office. But this office, at the front of the RV, has driver’s and passenger’s seats and a curtain that wraps around, covering the wide windshield.

Inside the RV, Oliver examines the abscess more closely. Denise’s husband rests against the backside of the driver’s seat. Oliver continues to ask casual questions—about Denise, her family, her living situation, her desire to be clean.

A few moments later, Dr. Flynn enters the room, and Oliver relays what she has learned.

“It’s red, warm to the touch. It’s painful to her,” she tells Flynn.

Well, Flynn says, leaning against the exam table, let’s have a look. He quickly assesses the inflammation and says antibiotics and hot patches applied several times a day should do the trick. No need to lance the abscess. It may not be bacteria, but simply the heroin inflaming the skin, especially if it was black tar heroin, Flynn says, speaking toward Denise but at the same time teaching Oliver.

“Yeah,” Denise confirms. “It was dirty dope.”

Oliver relays to Flynn that the couple is looking to get into The Effort, a Midtown drug-addiction counseling center.

“I’m glad to hear you guys are looking into a program,” Oliver says to Denise.

“Yeah,” she replies, with another one of those tired half-laughs. “I’m getting too old for this shit.”

Flynn prescribes doxycycline and asks if there’s anything else he can help Denise with.

“Is there some kind of cream I could put on it for the pain?” she asks, thinking of the bumping.

There’s no cream that would work, only pills, Flynn says. “It would have to be opiate-type things, and … I don’t think you need ’em,” he says. “You’re trying to kick it.”

The Joan Viteri Memorial Clinic is looking for doctors in the community to volunteer for four hours on a Saturday afternoon. The clinic also is looking for donations. To learn more about the clinic or to contact its organizers, visit its Internet site at http://cim.ucdavis.edu/clinics/Joan or call Harm Reduction Services at (916) 456-4849.