There were a lot of homeless people in New Orleans.  They were frequent patients at the Big Free.   Most interns and residents parked in parking garages within a block or two of Charity.  You would walk past many of these guys each morning and evening as you made your way to and from the hospital.  As a new intern, these guys were a little creepy.  They would usually ask for money and some would ask for medical advice.    Little did you know as an intern, you had just signed up to be team physician for the Camp Street Cowboys, the name given to this group by the house staff at Charity.   Many of them slept on Camp Street a few blocks away, thus earning their name.   By the end of your residency you knew many of these guys names and had done surgery on several.

There were a few basic rules you learned about this group as you trained at Charity.  First, these guys drank a lot.  During your workup history and physical you would ask, “Do you drink?”  Most would answer, “Doc I drink all I can get.”  If you asked are you drunk, they would all answer, “I ain’t drunk, but I have been drinkin at bit.”  As an orthopedic resident, we saw these guys for two main reasons.   First, drunks fall down and break things, usually a broken wrist or hip.  Second, they also had the tendency wander out in front of moving cars and break everything.  Taking care of this group took some unique thinking that was passed down from the upper level residents.

The main objectives was to avoid the DTs.  Delirium tremens is a serious medical condition caused by alcohol withdrawal.  Most Camp Street Cowboys would have symptoms of alcohol withdrawal within a day or two of stopping alcohol intake.  Symptoms would start with irritability and hypertension and tachycardia.  Without treatment, this could progress to hallucinations, seizures, and could be fatal.   If your patient started complaining of bugs and spiders in bed with them, it was a bad sign that the DTs were starting.  The worst, was a patient in skeletal traction having hallucination and seizures.  Anesthesia was not safe around the DTs, and any planned surgery would be postponed until the symptoms passed which could take several days.  DT patients were given sedatives, vitamins, and iv fluids and time to detoxify.  It was a disaster on an orthopedic ward for this to happen.

The Charity solution was simple, give the patient alcohol.  These guys weren’t going to start going to AA meetings when you discharged them.  They were going right back to the street and their bottle.   So alcohol was available for patients, not enough to get drunk, but enough to prevent the DTs.   The typical order would be a beer with each meal and shot of special spirits at bed time.  This translated into a Budweiser three times a day and shot of Old Crow at bedtime.  That would prevent DTs and actually save lives.   The down side to this was there was no privacy.  The patients were in ten man wards and would see their neighbor getting a Bud with meals.  The next time you made rounds, every patient on the ward was suddenly admitting to heavy drinking and a history of DTs.   Pretty soon, every patient on the ward was sipping a Bud.  Only at Charity.

Follow up care on the Camp Street Cowboys was also a unique challenge.  When discharged from the hospital they were given a follow up appointment to the orthopedic clinic.  Most were not responsible enough to keep an appointment.  Some would disappear and some would eventually show up in the ER wanting their cast off.   In most cases, you could not get an old chart at Charity and the Camp Street Cowboys were not good at remembering any details about their injuries.  To try to solve this problem, we would write on the cast.  We would put our name as the treating doctor, the date and type of surgery, and sometimes even draw the fracture on the cast.  It was a “walking medical record.”  This would usually work unless the cast was so filthy that it was illegible.

I can still remember having this conversation with one of the Camp Street Cowboys.  He somehow had shown up to the orthopedic clinic, he was several weeks late but there he was in a filthy long leg cast and a broken down wheel chair.  He still had on his hospital bracelet and several EKG stickers on his chest.  The writing on his cast was not legible.  The residents had rotated services, so we had a whole new crew of orthopedic residents at Charity.  No one recognized him or knew why he had a cast on.  I asked if he had surgery, he didn’t remember.  I asked if he knew is doctor’s name, he didn’t remember.  I asked if he remembered anything about being at Charity.  He said, “Doc all I remember is that they gave me plenty of cold Budweezer while I was here.”   At least he had fond memories of his hospitalization.

It was rank removing that cast.  I expected a horrible infected incision.  After cleaning things up, his leg and incision looked fine.  He had a plate and screws put in for a tibial plateau fracture.  He had worn the cast about six weeks longer than needed, but that did keep him non-weightbearing.  The fracture had healed, his knee was pretty stiff, but he was happy getting the cast off.  I never saw him again.





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