Dignity, love, compassion
By Norene Casas
Photos by Mark Sobhani
Pushing his walker across the floor tiles, the man shuffled into the clinic on a rainy Wednesday evening. Every two steps he took advanced his walker just an inch more.
Finally making it to the examination room, he sat still as a doctor began studying his weathered face and frail arms, identifying each pink, scaly spot as precancerous. Medical students gathered closely to learn.
“We will freeze this one,” said the doctor as he pointed to one of the spots. “This one I want to take a deeper look at as it might already be cancerous.”
As one of the city’s estimated 3,000 homeless, the man’s years spent in the punishing South Texas sun were scarred into his skin. The doctor provided much-needed medical attention, and students from the Joe R. & Teresa Lozano Long School of Medicine scribbled notes. This wasn’t a routine class in a lecture hall or lab. These students were learning more than can ever be taught in a classroom.
Since Haven for Hope opened its doors in 2010, UT Health San Antonio has offered a Student-Faculty Collaborative Practice at the resource center that provides services for more than 1,500 men, women and children every year who are experiencing homelessness in Bexar County.
From addressing chronic pain to emergency dental care to vaccines and treatment for skin ailments, the students put into practice what they learn in the classroom under the direction and supervision of faculty. In return, they offer the care that many homeless people lack.
According to the Centers for Disease Control and Prevention, the homeless population has a mortality rate that is four to nine times higher than those who are not homeless. There are an estimated 40 million people in the U.S. living in poverty, 19 million experiencing housing insecurity and 28 million who lack health insurance.
The risk of homelessness and poor health is a concern for 1 in 8 Americans, the CDC reports.
Because of their broad reach and deep impact, the Haven for Hope clinics offer valuable experience for students from all disciplines, said Richard P. Usatine, M.D., professor in the Department of Family and Community Medicine and assistant director of medical humanities education through the Center for Medical Humanities and Ethics at UT Health San Antonio.
“It’s about humanity. It’s about realizing that there are 7 billion people on this planet and we are all the same,” he said.
Dr. Usatine helped start the university’s first student-faculty collaborative practice in 2005. Over the years, it has expanded into a network throughout San Antonio that now offers six clinics—including the one at Haven for Hope—operated by medical, dental, nursing and allied health students.
“They can see that what they are really headed for is a life of service, not a life of memorization and testing,” Dr. Usatine said. “Their eyes are opened to so many different truths and things that extend their compassion.”
Within a year of the Long School of Medicine opening its clinic at Haven for Hope, students and residents of the School of Dentistry followed using clinic space in partnership with San Antonio Christian Dental Clinic to provide a wide range of dental services. It has since expanded to offer immediate emergency dental care.
The physical therapy clinic began in 2016, and gives students the opportunity to treat chronic pain in the homeless, most of it caused by poor health care and sleeping in inadequate conditions.
“People here are the least likely to receive health care in a private doctor’s office and, because they have the greatest needs, they are the most vulnerable,” Dr. Usatine said.
In addition to practicing techniques and procedures, students get the opportunity to practice empathy.
Students often believe “people living on the streets are different,” Dr. Usatine said, but after serving at Haven for Hope, they walk away with a story or two that impacts how they will provide health care in the future.
Holly Ann Ardoin changed her career plans after her rotation at the dental clinic. The fourth-year dental student saw patients who were around her age, but with teeth blackened and rotted by long-term methamphetamine use.
“I delivered a denture to a 25-year-old girl, and it showed me how strong addiction is,” she said. “I always felt like I was going to give back, go overseas and do dental work there, but I now feel there is so much need at home. There is work here to be done.”
Although it takes a lot of training to care for patients, it doesn’t take a lot to care. That’s an important message that Dr. Usatine wants students to take away from their time at Haven for Hope.
“We are all human beings, and everyone needs to be treated with dignity, love and compassion,” said Dr. Usatine. “Whether a person is homeless or using alcohol or heroin or methamphetamines, they deserve health care. They deserve to be treated well.”
Every time he sees a patient at Haven for Hope, first-year medical student Tommy Pham thinks about his brother. As the student director of the Haven for Hope dermatology clinic, Pham volunteers weekly and often serves patients who struggle with alcoholism and depression—two things his brother also struggled to overcome.
It was Pham who first saw the old man who slowly shuffled into the clinic on a rainy Wednesday.
Pham and other students examined his weathered skin imprinted with the brand of too much sun—too many days spent outside, without shelter.
When his appointment was over, Pham walked with him to the door and told the man how much he appreciated his patience with him and the other medical students.
“He finally looked up and looked me in the eyes. He had that old, really soft smile, and said, ‘Thank you.’ That is all he said. Really gently, just ‘thank you,’” Pham said.
“That look in his eyes, seeing him smile for the first time all night—it gave me a sense of hope. Then he turned around with his walker and went back to Haven.”
For health and hope
By Norene Casas
As she gushes about her 3-year-old daughter and her own good news of earning a four-year scholarship to college, Mariah Newton, 19, seems carefree, on top of the world, with endless possibilities ahead. Yet, less than a year ago, her story was bleak. She was a high school dropout. She was in and out of prison, a detainee of the youth detention center at age 15. She identified too many places as home as she bounced from one family member to another. She struggled to keep a minimum-wage job to support her daughter. When she found the Healy-Murphy Center, it offered her a lifeline.
The center provides respite to youth ages 14 to 21 in crisis by focusing on education, early childhood development and support services. Like Mariah, many of the young women there are pregnant or have children, with 40 to 45 percent identifying themselves as homeless. For 20 years, UT Health San Antonio’s School of Nursing has partnered with the center to offer health care and health education to promote healthier living to these at-risk youth.
“We didn’t just want to be a clinic where kids come in and get medication for their headaches. We are trying to screen them for other things going on in their lives: sexual behavior, drug use, food and housing insecurity—because we know those are attributed to poor health outcomes,” said Kathryn Parke, D.N.P., RN, CPNP, assistant clinical professor in the School of Nursing and clinical director of the Healy-Murphy Center. “If we just focus on ‘Why did you come see me today?’ that is not broad enough to take care of all their health concerns.”
Jane Smith, R.N., associate registered nurse in the School of Nursing, is the full-time nurse for the Healy-Murphy Center clinic and offers general health care and health-based classes to the 140 youth who seek help each year. With a background in labor and delivery, Smith also ensures expectant mothers receive the emotional support and prenatal education they need by enrolling them in the baby box program, which provides education and resources for low-income families. She also visits them at the hospital after their delivery.
Smith said forming a bond with the youth and connecting them to the right resources is her main purpose.
“I am the eyes and ears. I hear them talk about what is going on at home and how they are parenting,” Smith said. “I hear what we still might need to address.”
The School of Nursing supports the center with a range of care. A pediatric nurse practitioner offers on-site access to health care for their children. A psychiatric nurse practitioner offers evaluations and mental health care management, such as psychotherapy and psychopharmacology. A registered dietician offers breastfeeding support and information on healthy and affordable eating using the on-campus vegetable garden and cooking classes.
Nursing students also teach parenting classes that address a range of needs, from interpreting crying behaviors in babies to how to effectively communicate when feeling stressed or overwhelmed.
“If you just listen to what is going on in their world, you will understand a lot more,” Smith said. “We can identify that [person] is doing this because they might be depressed. We can help them with that issue because if we can treat the depression, we can treat the substance abuse.”
The nursing school operates with the understanding that each youth has a unique story. They recognize and address the social and economic conditions that affect their health and quality of life. They become investigators, digging for answers.
When a young girl asked Dr. Parke for medication to treat her low-back pain, Dr. Parke knew there was more to the story. Low-back pain is not a common complaint for adolescents. Dr. Parke later discovered the student had jumped out of her bedroom window—landing on her back—to escape a drug-related shooting that killed two family members. Beyond offering aspirin for pain, Dr. Parke connected the girl to the center’s counselor to address her trauma.
Another youth wrestled with obesity. When he began having chronic stomach pain, workers at the clinic discovered he had been skipping meals and, when he did have access to food, it was cheap, with little to no nutritional value. With the help of the dietician, he learned to choose healthier foods at no additional cost.
Mariah benefited from the school’s counseling services after her second daughter passed away after birth. It was solely through the resources at the center that she was able to work through her grief and graduate from the school, she said.
It’s the School of Nursing’s constant presence on campus, and its open-door policy, that leaves room for the youth to ask personal questions and have intimate conversations, Dr. Parke said. These conversations lead to the right care.
“These are things that, if you are not on the lookout for them, you are not treating the problem,” she said.
And for many of the youth, this is the only routine health care they have received in years because of a lack of insurance, inaccessibility and cost.
“I believe the fact that we are there means they get the resources that they wouldn’t have gotten before, and because we are there, they get the sense of connection that someone cares for them,” Dr. Parke said.
Douglas Watson, executive director of the Healy-Murphy Center, said School of Nursing faculty and students “come with no judgments; they come with that open heart.”
“We help those who come to us who have given up hope,” he said. “They come without hope because many of the systems in their lives have failed them or disappointed them. We will help them find hope again because of the caring people we have here.
“As individuals, we have to have hope in order to lead good and successful lives.”
Months after first seeking help at Healy-Murphy, Mariah is a different person. She is no longer the troubled drifter. She is now focused on going to college, graduating and creating a better future for her and her daughter.
Today, it’s the simple things that matter most.
“I want to give my daughter what I didn’t have in my life. I didn’t have anyone helping me with homework,” she said. “I just want to be there and help her with her homework.”
Care from someone who knows
By Norene Casas
Everyone has a story. Vidal Balderas, D.D.S., M.P.H., recalls his own as he delivers dental care to high-need communities.
Dr. Balderas, associate professor in the School of Dentistry, was born on the South Side of San Antonio and raised along the border near Eagle Pass, Texas. He spent his early years as a migrant worker, laboring alongside his family in fields throughout South Texas.
San Antonio Christian Dental Clinic. The clinic provides free dental care to homeless and underserved adults.
It was an accident with a machete that gave him his first clue that he was destined to help others. He was working in the fields when he struck his knee with the tool. Blood immediately spewed from a wound so deep he could see his bone.
His brother saw the wound and collapsed. Unfazed by the blood, Dr. Balderas only felt concern for his brother. This is the moment he knew he was meant to serve others.
“We have something inside that makes us want to help,” said Dr. Balderas. “An inner feeling of wanting to serve.”
He enrolled at the School of Dentistry at UT Health San Antonio while also working at a local grocery store. His father would often ask why he was spending so much time and money going to school when he already had a good job, but Dr. Balderas had other aspirations.
Through the dental school’s outreach programs, he traveled to developing nations, and the experience changed his view of health care.
“You start to see the world a little differently when you come back from a mission trip. You learn poverty is universal and you become conscious of other people’s needs around you,” he said.
He began seeing people who shared life stories that were similar to his own: low-income families working long hours to pay for basic necessities. Families for whom routine health care is viewed as a privilege. He listened to their stories and adjusted his care based on their needs.
Dr. Balderas graduated with his Doctor of Dental Surgery degree from the university in 1984 and continued with a master’s in public health and a residency in dental public health. Remaining connected to his roots, he began the San Antonio Independent School District Migrant Farmworker Children Mobile Van Program, providing free dental care to children of low-income migrant farmers.
He’s heard countless patient stories through the years. But there is one that stands out, one that was never finished.
The patient had an unusually quiet demeanor and appeared very frail. Her medical file showed a consistent drop in weight throughout her visits. Based on the extensive amount of acid erosion on her interior front teeth, Dr. Balderas suspected she suffered from bulimia. He arranged a follow-up appointment at a nearby community health center to address the disorder, but she never made the appointment.
They went to her apartment, only to find it empty. He never saw her again.
Her story remains with him, and pushes him to always work hard to better understand his patients.
Dr. Balderas continues to provide dental care in various community-based clinics. He also teaches School of Dentistry students and residents. During clinical rotations at Haven for Hope, a campus near downtown San Antonio that offers care and housing for those experiencing homelessness, he reminds his students that each person has a unique story that has brought them to where they are today.
“Some people can’t help where they are, but we are the missing pieces,” said Dr. Balderas. “We all can do something for those who have no voice.”
If a patient is agitated, he reminds them what they, as health care providers, are there to do.
“Look at the pain that is present. What can we do to provide them comfort?” he asks his students. “As health care providers, [we] are committed to try to improve the health of that individual, to repair and help people wherever they are at.”
To have and to hold
By Norene Casas
When Valerie Taylor became pregnant with her first child in 1976, she was overjoyed, filled with love and hope for her future as a newlywed and a soon-to-be mother of a baby girl.
“All I ever wanted to do was be a mommy,” Valerie said.
Then, six-and-a-half months into the pregnancy, she began experiencing severe abdominal cramping. She waited for what felt like hours for the doctor in the hospital’s overcrowded waiting room. A nurse noticed Valerie hunched over, cradling her belly in fear and pain, and moved her to a delivery room. The next thing she remembers is waking up the following day, asking to see her baby. “I’ll get your doctor,” the nurse responded gravely.
No one would talk about her baby’s death. Valerie and her husband, Roger, suffered and mourned their daughter, whom they named Melody Jewel, alone. They even changed churches, as parishioners began to avoid them over fears of how to address the couple’s loss.
At a follow-up visit a few weeks later, a nurse, unaware that Valerie’s baby had died, asked about her daughter.
“I got so excited that somebody was asking me about my baby. Nobody had done that,” Valerie said. But after she told the nurse of her daughter’s death, the nurse “didn’t say another word and walked out of the room, and I just stood there thinking, ‘She really didn’t care. Nobody cares. Nobody knows.’”
A few years later, Valerie became pregnant with a boy. At seven months, she felt the same abdominal pain that led to her daughter’s early birth and death. This time, Valerie knew what was going on, and what was going to happen to her baby. And once again, she felt terrified and alone without any support from the hospital staff.
As his heart rate began to drop from 90 to 60, the nurse came into the room to remove the monitor.
“In my head, I just kept saying, ‘Oh, please let me hear, that’s all I am ever going to hear of my baby.’”
They named him David. This time, after he died, she asked the nurse to hold him, and only reluctantly did the nurse comply. Then Valerie asked the doctor to let her husband in the delivery room so he could also see their son.
“I have no pictures. I have nothing,” Valerie said.
Lessons in loss
When a child dies at birth, nothing is routine. Tests and medical procedures suddenly stop. Instead of the wailing of a newborn, there is silence. Years ago, this was also where the patient’s care ended. Today, nurses are realizing this is a critical moment when the standard of care should strengthen. This is the beginning of the family’s journey to healing, and as health care providers, nurses are a vital component in that journey.
“It is an honor and privilege to be in a patient’s life,” said Laura Sisk, D.N.P., clinical assistant professor in the School of Nursing. “We have that important responsibility of making that situation as bearable as possible for them.”
Valerie would later have three more children, two girls and a boy. All were carried to full term and are now adults with their own children, and Valerie is a grandmother of six. But she’ll never forget the two children who came before, and she shares her experiences of losing those babies with nurses and nursing students to help them understand their role in providing compassionate care.
“The color of my world changed,” Valerie told the students. “It will never be the same.” She explained how meaningful it would have been if a nurse would have taken the time to go into her room and talk to her about her child. “Just going in and even saying I am so sorry that your baby
died. Asking ‘Did you name your baby?’ Talking about the baby to the mom. I know that moms would love to hear that you are acknowledging they had a child. I don’t think I got that.”
One of Valerie’s daughters, Angela, also joins her in the presentations. She, too, has her own story of loss. It was March 5, 2003, when her son, Christian, was born four months early. He was only 1 pound, 4 ounces.
Angela remembers looking at Christian in the neonatal intensive care unit, longing to be closer to him.
“He needed me to hold him and cradle him. He needed to feel warmth, but so much more than he needed those things, I needed to do them,” she recently told the nursing students. “I needed to see him dressed and cradled; I needed to love him.”
She would spend the next days and nights walking to and from her son’s bedside. One night, she broke down. A nurse saw Angela crying and quickly rushed to her side. She sat her in a chair, squeezed her hand and asked Angela for her son’s name. She told Angela she would check on him to make sure he was still OK.
The nurse came back with small heart-shaped plaster ornaments of Christian’s hands and feet tied at the top with a light blue ribbon.
“She was making me a precious gift, a part of my son that I would have forever,” Angela said.
Four days after Christian was born, it was time for Angela to say goodbye. The nurses provided Angela a room for privacy, a safe place to hold him without tubes and wires, a dress, booties for his feet, and a bonnet. Together, Angela, Valerie and Valerie’s husband held Christian and took photos of him.
“This picture,” Valerie said, displaying a picture of her husband holding baby Christian gently up to his cheek. “That’s what we wanted to do with our children. We just wanted to hold them and love them, and we weren’t allowed to.”
Valerie struggled with wanting to hold her grandson and supporting her daughter.
“I had to wait until she was finished holding him. That was hard for me, but I knew she needed to do it and get through it,” she said.
Valerie was not allowed to dress either of her children for burial. But Angela had a different experience, one she shared with her mom. In the hospital room, Angela asked her mom to dress Christian.
“She allowed me to dress him,” Valerie said. “It was very healing for me because I wanted so much for my babies to be in a beautiful little dress.
“When we were together holding Christian, we were not only holding our grandson. We were also going back 30 years. We were grieving our children through Christian.”
Building memories
Although patient care has come a long way since Valerie’s experiences, Dr. Sisk believes there is still more to do to prepare students. To help, the school has supplemented the core nursing curriculum with a program dedicated to perinatal loss to teach them how to become compassionate healers. Students hear firsthand from mothers like Valerie and Angela who lost a child, and are reminded of how critical their role as nurses will be at these moments.
“I had to do a better job at getting them ready to take care of these families. I needed to do a better job for the families because they deserve compassionate healers,” said Dr. Sisk.
The perinatal loss program, offered a week before clinical rotations in obstetrics and gynecology, teaches students how to communicate with families who have lost a child. The school’s simulation lab is a safe learning setting where students can practice speaking with a mother about her child and offering the support she will need. Here, with actors and simulation mannequins, students learn to listen to their patients, as each person experiences and copes with loss differently.
The program teaches the students to create memory boxes and plaster footprint ornaments as keepsakes, much like the nurse who made the plaster ornaments for Angela. Some students paint the boxes in a light blue color; others paint a small heart or angel on the lid with flowers around the edges. In one class, a student shared the memory box she received after her own daughter died. The box carried a card from the nurses, a tiny bracelet with her daughter’s name spelled out with beads, and a heart-shaped ornament of her daughter’s footprints.
“Parents have very empty arms when they leave the hospital, so having the memory box with the footprints or a baby bracelet—those are tangible things they can hold onto,” said Dr. Sisk. “Perinatal loss isn’t like any other loss. They haven’t had a lifetime of making memories, so we need to create those memories for the families.”
The memory boxes created in the class are donated to local hospitals.
Such gestures “help keep the memory of the child they have lost alive,” said nursing student Mili Petrozzi. Hearing the stories told by Valerie and Angela and learning about the unique nature of perinatal loss “gives us more of a foundation to help support these moms through such a tragic loss.”
As the students prepared for clinical rotations, Angela expressed her gratitude to the neonatal intensive care unit nurse who showed such compassion the night she lost her baby in 2003, and to the future nurses for the comfort and healing they will someday offer to others like her.
“The earthly tangible things you give mothers like me are so important and special,” she said. “I had a baby, and you made my memories of him real. I am a mother and you helped me feel like one.”
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Sweet dreams
Yldenfonso Vasquez Jr. knew he snored. His wife told him—often. And when he had to travel for work, sometimes sharing a room, his coworkers would tell him they were afraid he was choking in the middle of the night.
“He was snoring really loud,” said his wife, Catalina Vasquez. “I was worried something was going to happen to him.”
Sleep apnea’s common symptoms—loud snoring and daytime sleepiness—may seem minor. But left untreated, sleep apnea can lead to high blood pressure, heart attacks, congestive heart failure, stroke and increased risk of developing or worsening diabetes. Researchers have also discovered that obstructive sleep apnea patients have an increased risk of death from any disease, such as cancer.
An estimated 18 million people in the U.S. have sleep apnea, though many go undiagnosed, according to the National Institute of Neurological Disorders and Stroke.
“There is such a health care crisis involved with this problem that we are trying to get people educated and treated,” said Ann Larsen, D.D.S., clinical director of the Sleep Disorders Center at UT Dentistry, the patient practice of the School of Dentistry.
So many cases are undiagnosed, Dr. Larsen said, because of the public’s lack of knowledge of the risks. And symptoms, like snoring, are thought to be a common nuisance rather than a legitimate health risk. Compounding the problem, she added, is that a patient’s quality of sleep is often not discussed during routine primary care appointments.
“There is a common misconception that it is normal to be tired or snore,” Dr. Larsen said. “It is not normal.”
UT Dentistry opened the Sleep Disorders Center to become part of the solution, using a dental approach to offer another treatment option—a customized oral device that fits inside the patient’s mouth.
When a patient is diagnosed with sleep apnea, physicians can prescribe a continuous positive airway pressure device, also known as a CPAP. The machine uses mild air pressure to keep the breathing airways open. A mask or other device covers the nose, or nose and mouth, and straps around the head. Air is pumped through a tube that links the mask to the machine’s motor.
The inconvenience of the size and fit, as well as the idea of wearing a mask to sleep, may deter people from seeking treatment, Dr. Larsen said.
Prescribed a CPAP by his physician, Vasquez struggled with anxiety and discomfort from the machine. He moved a lot in his sleep, and would sometimes knock the machine off the nightstand.
It also caused minor injuries.
“It would bruise his nose,” his wife said. “It was just uncomfortable.”
Vasquez tried surgical treatment options. His tonsils were removed and his uvula was reduced. He had surgery to realign his jaw. Still, he snored.
Then he was fitted for the oral device. About the size of a retainer, it moves the jaw forward, increasing the size of the upper airway and reducing the air resistance that leads to snoring and sleep apnea.
“Dentists are highly trained in the anatomy of the teeth and mouth,” Dr. Larsen said. “We play an important role in helping to treat sleep apnea with oral appliances.”
At the Sleep Disorders Center, patients like Vasquez are carefully screened through a physical exam and questionnaire to gather information about sleep habits. If there are signs of sleep apnea, the patient is given a small monitoring device to wear during sleep that straps around the chest and measures the patient’s heart rate. A small plastic tube placed just outside the nose measures oxygen flow and exertion rate, and records the number of times the patient stops breathing. Results are then electronically sent to a sleep physician for diagnosis and, if warranted, recommendations for the oral appliance are sent to the dentist.
The dentist then takes digital or physical impressions and models of the teeth to ensure a customized fit. At the center, the appliance is tailored specifically for each patient’s needs. If a patient frequently drinks water at night, a two-piece device is recommended that allows the mouth to easily open and close. If a patient is a teeth grinder, there is a device covered with a thick layering that prevents damage to the teeth and appliance. Appliances can also be fitted for certain facial features and characteristics.
Follow-up visits with the dentist are scheduled to adjust the appliance, if needed, to maximize comfort and effectiveness.
The device is compact, portable and requires no electricity. And for Vasquez, it was what he needed to finally get a good night’s sleep. He feels more energetic and alert.
“I just have to put it in at night, then I am done,” he said.
His wife notices the difference, too.
“It is a lot quieter,” she said with a light laugh. “I can get a better night’s sleep too, and I am happier. There was a big concern when they said he could have a stroke or heart attack. I don’t worry as much anymore.”