Working in shelters near the U.S./Mexico border, providers practice challenging medical care under limited time constraints.
Shelter residents “have everything that other people have, and then some things because they’ve made an arduous journey,” such as broken bones, said Dr. Kathy Fischer, a physician associated with the University of California, San Diego, and the medical director of a team working in local shelters run by Jewish Family Services of San Diego and Catholic Charities, Inc. “We see people right after [the Department of Homeland Security] releases them from detention or custody, and all the people are going to be leaving within one or two days,”
But sometimes, things come easily.
During a shift, physician assistant John Hofisi came across a shelter resident from Mexico who was HIV positive – and who had been off her essential medication for two weeks, after taking it consistently for several years.
“You need to be taking your medication every day,” Hofisi said. “You’re trying to suppress the virus…If you don’t take your medication for a long time, you can develop a resistance.” In addition, he said, the immune system can be further suppressed, opening a patient up to opportunistic diseases.
Because different HIV treatments work in different ways, one simply can’t be substituted for another. And because of the possibility of resistance, the team didn’t want to provide an inadequate supply.
“And then, oh my gosh, we had the meds,” Fischer recalled.
Screen and stabilize
Providers on Fischer’s team don’t always get so lucky. When they’re working in the shelters, they have two goals: screen and stabilize. “We want to give them the best care we can, but we also don’t want to hold them up,” she said.
Residents come from all over the world, according to Fischer. Her team has treated patients from Central America, Europe, the Middle East, and East Asia, among other regions. After leaving the shelter, most people will travel elsewhere in the U.S. to meet their “sponsor” – a person who helps an immigrant become a permanent resident.
To prepare them for their travels and new home, providers screen for contagious diseases such as Covid-19, tuberculosis, and influenza, and make sure that patients with chronic diseases, injuries, pregnancies, or other medical conditions are treated appropriately.
Some of the doctors, physician assistants, and other providers are comparatively experienced; some are residents or trainees. Learning to care for patients quickly and efficiently is a valuable skill, she said.
The short window for treatment sometimes means making difficult decisions. A patient who’s gone off medication may need labs before they restart a course of treatment, for example. Another may need a specific medicine that isn’t immediately available.
“You do have to make the best decision in the moment because you’ll probably never see that patient again,” Fischer said. “It’s a different way to practice medicine, but it’s still a good way.”
“A feel-good moment“
Treating Hofisi’s patient with HIV was a particularly triumphant moment for the team.
The patient’s treatment – a combination of the drugs efavirenz, emtricitabine, and tenofovir – was an unusual one in the United States, but Fischer had recently requested it from Direct Relief. “They’re not the most common, but people are coming from all kinds of countries, and [I thought] some of them might be on them,” she said.
The drug combination prevents the HIV virus from replicating, by acting on a particular enzyme called HIV-1 integrase, Hofisi explained: “It keeps the viral load down.”
On the day they realized they had the medication, “it was a very feel-good moment,” Fischer said. Hofisi was scheduled to work in a different shelter, but she filled in for him, so he could give the patient the good news. She received enough of the combination to see her through getting established with a medical provider.
“She felt really heard, and she felt really safe,” Hofisi said of the patient. He provided her with the medication, and she left shortly after.
And for the staff, it was a meaningful experience. “We take all of our wins very seriously here. People arriving to the country, we want to treat them with dignity, we want them to feel welcome,” Fischer said.
“It’s really amazing work, that gives kind of a purpose to the provider as well. Sometimes we can be the first positive thing they see, and that can really make a lasting impression on their whole life,” Hofisi said.