Trust and RV Medicine

SCRAPPY IS BARKING AT ME AGAIN. He assumes his customary demeanor — carton of concerned suspicion — and arranges his paws equidistant from one another on the cement patio.

I call his name. He blinks.

I step forward, woo him with kind remarks about his scanty white fur, his mangled ears. He lowers his prominent head an inch and looks beyond his wrinkled brow in a poignant mixture of longing and skepticism.

I inch closer, hand extended toward his whiskered snout, and wait for the bull dog to initiate the next step in our weekly interaction. Then suddenly and not unremarkably, he changes completely; his body wriggles with pleasure and he stumbles forward, claws clicking on the ground, tail thwaping from side to side.

A relieved whimper rumbles in his big chest, he thrusts his shoulder toward my calf, and at last Scrappy is mine once again.

For the rest of the morning, the adopted mascot of Harm Reduction Services will follow me happily as I traverse their back patio to stock the RV, and as I climb the stairs carrying patient charts. He will remember me later this evening when I help the other students unload medical supplies and dispose of garbage.

Next week, however, we will have to meet one another once more, and I will think, It's shocking how long it takes to gain the trust of someone who's been mistreated.

We are at the Joan Viteri Memorial Clinic (JVMC), a free, mobile clinic with the primary purpose of serving injection drug users, sex workers (I'm avoiding the usual pejorative descriptions) and their families.

The clinic is managed and run by volunteer students. We spend our lunch hours grappling with budgets (we are in the red), dispensary formularies (we only just started taking Pharmacology) and the writing of extensive protocols (to be finished in the day's twenty-fifth hour). Despite the challenges, however, our clinic opens almost every Saturday, and serves one of the most indigent, underserved and stigmatized populations in Sacramento County.

It was not until last spring that we were actually able to connect with this community. On May 19, 2003, the co-directors of JVMC stood in the dry, hot dirt of the 40th Street Oak Park alley way, clad in white coats and wielding clipboards, looking up and down and half expecting patients to come running up the street. We had just reopened after a four-year hiatus.

Despite countless hours of preparation, punctuated by an earnest desire to understand our patient population, many students were shocked by the profound need that manifested itself almost immediately. This need, however, would ultimately enable us to earn a place in a community that we find to be remarkably vibrant.

Named for a woman who died in 1997 of preventable complications related to injection drug use, the Joan Viteri Memorial Clinic was established in the belief that no person should be cut off from basic, life-sustaining health care. The clinic itself is mobile, run out of a 45-foot RV and equipped to operate at various locations.

As a specialty clinic for high-risk populations, JVMC fills a neglected niche by serving patients that often face strong discrimination from the greater healthcare community. A pariah among even the most stigmatized patients, an injection drug user who looks for support in the medical community is seldom treated with respect and kindness.

JVMC strives to prevent emergent, life-threatening conditions by providing early intervention and unbiased health care. We work in accordance with "harm reduction," a practical approach to reducing the negative consequences of drug use and other risky behaviors by employing strategies that meet patients "where they're at." Instead of demanding that they change their lives, we share information and counsel patients in ways that will truly allow them to move in a direction that they choose.

Thus, the main goal of this clinic is to preserve health in drug users and sex workers and to reduce negative societal impact of these lifestyles. After all, such choices should not preclude individuals from deserving care.

Our clinic provides basic healthcare services, gynecological exams, STD screening and perhaps most importantly, surgical care for abscesses acquired during injection drug use. A limited dispensary allows us to prescribe and provide free antibiotics, which are often packaged in a brown bag containing condoms, education material and safer injection aids — clean tourniquets, bleach solution, cookers, alcohol swabs and cotton balls. Although frustrated by our legal obligation to withhold clean syringes, we prioritize both public health and harm reduction and know that at least we are moving in the right direction.

In addition to taking histories and performing physicals, students working at the clinic have the opportunity to observe and perform abscess incision and drainage, phlebotomy, and female exams. Patients are encouraged to return on subsequent Saturdays, and there is ample opportunity for follow up on chronic clinical and mental health conditions.

JVMC is but one of the six student-run clinics in Sacramento. The opportunity to volunteer at and manage these clinics is unique to UC Davis Medical School, and gives students early experience with clinical medicine while providing a valuable and oft-used service to the community. The clinics rely entirely on grants and donations to operate and provide medical care completely free of charge.

Volunteer physicians are an essential component. Not only do they enable the provision of healthcare, but they direct and cultivate the students' educational experience.

The chance to find mentorship at JVMC is remarkable. The clinic is partnered with Harm Reduction Services of Sacramento, a community service organization that works towards prevention of infectious diseases through street outreach, HIV testing, and provision of drug-related, medical and social referrals.

Students are thus able to explore the nuances of social work and risk assessment. Additionally, the clinic is guided by the unparalleled dedication and experience of Dr. Neil Flynn of UCDMC Center for AIDS Research, Education and Services (CARES) Clinic.

Unfortunately, JVMC has closed on several Saturdays due to lack of an attending physician. University guidelines regarding volunteership have recently changed, however, enabling the recruitment of non-faculty physicians. It is thus that we find ourselves reaching deeper into the medical community in hopes of finding doctors who are able to donate time to this valuable healthcare and educational service.

As both a co-director of JVMC, and an advocate for a population that has become close to my heart, I am deeply invested in the continued existence of the relationship we have built with this endearing, albeit disadvantaged, community. The patients I help serve at JVMC are, somehow, both vulnerable and courageous. It is an honor to play a role in their healthcare; their gratitude and perseverance helps define me as an aspiring physician.

And, most importantly, I am indebted to them for teaching me that trust doesn't come easy, and it must be earned by both parties.

I think Scrappy would agree. It needs compassion, and time.

elven@ucdavis.edu