Guidelines For Working In Homeless Clinics

Introduction
Below are some commonly asked questions & topics which we have endeavoured to cover based on experience within homeless & socially isolated settings, as suggested guidelines for working in homeless clinics.

Overview
People we see range across rough sleepers, sofa surfers, those in shelter and people who have recently moved into accommodation, to those considered socially isolated and on the poverty line.

There is a higher level of mental illness within the homeless & socially isolated population along with drug and alcohol abuse which can at times be quite challenging.  Also, homeless/rough sleepers are generally a fairly transient population.

This all makes any continuity of treatment difficult if not impossible.

The podiatry service we offer through the Forgotten Feet project thus tends to be of a basic short-term nature and aims primarily to alleviate pain, replace worn out or ill-fitting footwear to prevent further problems, and help with simple biomechanical issues, as well as to show compassion – an important consideration.

Men have often come from broken relationships/marriages, been obliged to leave the marital home, and then spiralled downwards towards alcoholism.  Younger men may have been in and out of prison for crimes relating to drugs.

Women very often are victims of abuse at home or in the care system, and have run away & turned to drugs and prostitution to support the habit.  Women living on the streets are often abused by male rough sleepers.

People put into accommodation often don’t like it and will return to the streets where their friends are.  A minority are entrenched homeless and prefer that way of life.

There are numerous other factors relating to homelessness; these are simply a few of the ones we commonly encounter.

Sign Posting
Research has shown that those taking up the offer of a podiatry service are far more likely to see other health care professionals.

People often want to talk about other serious issues they may have, and thus it is useful to have local phone numbers of e.g. rape crisis centres, emergency shelters, local GP’s, drug & alcohol advisory services to name but a few.  A well set up drop in-centre should have these numbers to hand and staff to deal with them.

Consent
Gaining consent to begin treatment is a simple verbal agreement, and patient notes are perforce very brief as quite often people do not wish to tell you any more than their name and date of birth. They are generally quite suspicious or mistrusting at first, medical histories are often, if given, not accurate, and people will lie about infectious disease.  You must therefore treat everyone as high risk.

On each person’s notes, do ensure you have date, treatment given, anything given out and signature as a record – currently, we just use postcards for each person.

Always ask permission for any photographs, as some will refuse, and others won’t want their faces in the shot.

Treatment
Treat everybody as high risk and conservatively.

Sharp debridement if necessary, don’t over debride and keep the risk of cutting anyone to a minimum – this reduces the likelihood of blood contamination and thus the possibility of anybody getting an infection, which is highly likely due to unsanitary conditions.

Use dry dressings if needed, and take extra care with possible ulcers.

Treatment will vary according to patient compliance and whether they are willing to seek further help if required.

Commonly seen complaints
Pitting keratolysis (use plenty of antibacterial spray on this – debride well), corns, calluses (heavy) – often with extravasation, fungal skin and nail infections, long thick nails, along with an array of other conditions, some really interesting.

Equipment
A basic doms bag is adequate, a headlamp is often useful, and of course plastic aprons, non-sterile gloves, and couch roll.

You will need two chairs – one each for operator and patient – a footstool if you have one is very useful, and paper towels.

Safety
Treat all as high risk, beware mental illness which isn’t always apparent straight away, and don’t trap yourself in a corner – keep an escape route.

If you are on your own keep the door open.  Keep only what you need on show, don’t leave a scalpel with a blade anywhere within easy reach.

People are desperate and may try to steal items of value to sell – never leave a doms bag unattended and try to ensure a member of staff is within earshot if you are on your own.

As long as you keep these precautions in mind and are sensible, almost anywhere is possible to offer a simple service; it doesn’t need to be in a smart clinic – we have treated in a secluded corner of a church as well as in separate rooms.

Kindness
Always be kind – this is one of the most rewarding things you will ever do!