ALLENTOWN, Pa - Nurse Laura LaCroix was meeting with one of her many homeless patients in a downtown Dunkin' Donuts when he mentioned that a buddy was lying in agony in the nearby woods.
"You should check on him," said Pappy, as the older man is known. "But don't worry, I put him on a tarp, so if he dies, you can just roll him into a hole."
LaCroix called her boss, Brett Feldman, a physician assistant who heads the "street medicine" programme at Lehigh Valley Health Network. He rushed out of a meeting, and together the two hiked into the woods. They found Jeff Gibson in a fetal position, vomiting green bile and crying out in pain from being punched in the stomach by another man days earlier.
Feldman told him he had to go to the hospital.
"Maybe tomorrow," Gibson replied.
"Tomorrow you'll be dead," Feldman responded.
Months later, the 43-year-old Gibson is still in the woods, but this time showing off the six-inch scar - for a perforated intestine and peritonitis - that is evidence of the past intervention. He greets Feldman warmly. "You're the only person who could have gotten me to the hospital," he said. "You're the only person I trust."
Pappy and Gibson are "rough sleepers", part of a small army of homeless people across the country who can't or won't stay in shelters and instead live outside. And LaCroix and Feldman are part of a burgeoning effort to locate and take care of them no matter where they are - whether under bridges, in alleyways or on door stoops.
"We believe that everybody matters," Feldman said, "and that it's our duty to go out and find them."
Most of the time, members of his team provide basic primary care to people who live in dozens of encampments throughout eastern Pennsylvania's Lehigh Valley. During their street rounds, they apply antibiotic ointment to cuts, wrap up sprains and treat chronic conditions such as blood pressure and diabetes.
But they also help people sign up for Medicaid, apply for Social Security disability benefits and find housing. Three or four times a month, they deal with individuals threatening to commit suicide. After heavy rains, they bail out "the Homeless Hilton", a campsite under an old railroad tunnel that frequently floods - and where two rough sleepers once drowned. Many days, they simply listen to their patients, trying to relieve emotional as well as physical pain.
Street medicine was pioneered in this country in the 1980s and 1990s by homeless advocates Jim O'Connell in Boston and Jim Withers in Pittsburgh. Yet only in the past five years has it caught fire, with a few dozen programmes becoming more than 60 nationwide. A recent conference on the topic in Allentown drew 500 doctors, nurses, medical students and others from 85 cities, including London, Prague and Delhi, India. Most programmes are started by non-profit organisations or medical students.
Even as it comes of age, street medicine faces new challenges. A younger set of leaders is less interested in cultivating a bleeding-heart image than in establishing the approach as a legitimate way to deliver health care not only to the homeless - whose average life expectancy is about 50 - but also to other underserved people. Backers say street medicine should be considered a subspecialty, much like palliative care is, because of the unique circumstances of treating its target population.
Proponents also are pressing for much more financial support from hospitals, which can benefit greatly when homeless individuals receive care that helps keep them out of emergency rooms. Feldman's programme - which includes the street team, medical clinics in eight shelters and soup kitchens, and a hospital consult service - has slashed unnecessary ER visits and admissions among its clientele. The result, to the surprise of Lehigh Valley Health Network officials, was a $3.7 million boost to the bottom line in fiscal 2017.
Perhaps the biggest issue facing street medicine, however, is figuring out how to provide more mental-health services. About one-third of homeless people are severely mentally ill, and two-thirds have substance-use disorders. Long waiting times for psychiatric evaluations delay needed medications and, in some cases, opportunities to get housing.
Psychiatrist Sheryl Fleisch is working on that problem. In 2014, she founded Vanderbilt University Medical Center's street psychiatry programme, one of a few such initiatives in the country. Every Wednesday morning, Fleisch and several medical residents visit camps in Nashville, handing out shirts, blankets - anything that can build trust.
Then they split up to talk one-on-one with people waiting on park benches, at bus stops and in fast-food restaurants, providing a week's worth of prescriptions as needed. Fleisch said these homeless patients almost never miss an appointment.
Many "have been thrown out of other programmes or are too anxious to go to regular office sessions," she said. "We have some patients who will get up and sit down 15 times during our appointments. We don't give up on them." On a muggy fall morning, Feldman's team makes its way from the Hamilton Street Bridge in downtown Allentown to a swath of mosquito-infested woods between the railroad tracks and the Lehigh River. A few blocks away, an extensive redevelopment project, complete with a luxury hotel and arena for the minor-league Phantoms hockey team, is revitalising parts of the long-depressed area.
Bob Rapp Jr, who has worked extensively with homeless veterans and knows the location of many campsites, is the advance man. "Good morning! Street medicine!" he calls out.
LaCroix uses her "Mary Poppins bag" to try to coax people out of their tents: "We've got supplies - socks, toilet paper, tampons!"
A thin woman with striking blue eyes pops out of a tiny tent, pulling at her wildly askew blonde hair as she glances in a mirror propped up against a tree. Her toenails are painted gold. A Phillies cap and a Dean Koontz book, ‘Innocence’, sit on one of her two chairs.
"Tampons!" exclaims the woman, who identifies herself only as Duckie. "I just turned 60. I don't think I need tampons!" She hugs LaCroix, with whom she bonded after the nurse helped her get new clothes and emergency treatment for a virulent, highly contagious skin infestation called Norwegian scabies.
Feldman kneels in front of Duckie with his stethoscope to check her lungs; the last time he saw her, the longtime smoker had bronchitis. No breathing problems this time, but Feldman tells her he wants a psychiatric evaluation. If the doctor confirms that she has bipolar disorder, depression or post-traumatic stress disorder - all diagnoses Duckie said she has heard over the years - she will be able to get the drugs she needs and perhaps transitional housing.
"I self-medicate," she shrugs. But she likes the idea of moving inside with winter coming.
"It stinks out here," she said. "It's cold. I have to watch out for rats and raccoons and people." She agrees to see a psychiatrist - a volunteer who comes out once a month - at her tent the following week.
Later in the day, the team goes to see a favourite patient. When the group approaches his plastic-covered hut in the woods, Mark Mathews frantically orders them to stop. "I don't want to be caught with my pants down!" he yells from within.
Moments later, khakis on, the 57-year-old emerges. The son of a successful Allentown actor, the grey-bearded Mathews spent years playing Santa Claus in malls. He also worked for a high school theater department and in the 1980s was part of a local-cable comedy show ‘Sturdy Beggars’.
He became homeless after having a falling out with his sister four years ago. "The money ran out, and I couldn't get another job," he said.