Look up, not down

In his book, Stories from the Shadows,²⁰ physician James O’Connell writes about establishing trust on the street by reversing the typical doctor-patient relationship. Approaching his patients with an attitude of nonjudgmental respect and unconditional kindness, he sheds his white coat and gets down on the sidewalk or park grass with his patients, and listens. Dr. O’Connell, and the many physicians he has trained in street medicine, initially focus on the condition of their patients’ feet, since those patients typically walk many miles, often starting treatment with a foot bath and treatment of any wounds or diabetic ulcers. Establishing trust with pet owners, and their pets, is a required first step in providing care and is more likely accomplished by looking up rather than down.

Doing more with less

History and physical examination become the key diagnostic tests in street medicine. Not unlike emergency medicine, street medicine often relies on owners’ observations of how their pet seems to be doing in determining the seriousness of a condition and whether to treat or refer. Basic diagnostic tools such as glucometers, BUN reagent strips, urine dip sticks, and refractometers for assessment of urine specific gravity are helpful in ruling out diabetes mellitus, renal failure, and urinary tract infection in dogs and cats. When pale gums or lethargy suggest anemia, small, patient-side hematology analyzers (eg, the Hb 201 from HemoCue America) can provide an accurate hemoglobin measurement. Other methods of estimating blood hemoglobin concentration in the field are also being explored by examining the color of a drop of blood using the World Health Organization hemoglobin color scale.²¹ The use of an ophthalmoscope-otoscope, proparacaine, Schirmer tear test strips, and fluorescein stain, along with otic or ophthalmic medications (eg, otic solution containing florfenicol, terbinafine, and mometasone furoate), can effectively be used to treat common ear and eye conditions. Use of newer medications for atopy and allergic skin disease (eg, oclacitinib) make treatment for these conditions more successful, in part by reducing the need for a multimodal approach and challenges with compliance when more traditional treatments are used. When a source of electricity is available, a microscope can be used to examine cytology samples, ear swabs, and skin scrapings. Higher-technology diagnostic equipment such as an FDA-approved (for human use) ECG application (eg, KardiaMobile from Alivecor Inc) and a wireless ultrasound probe (eg, the CH3 HD multipurpose scanner from Santa Cruz Animal Health) linked to a phone or tablet can be effective screening devices and effective ways to assess for pregnancy or diagnose a heart condition. Electronic medical records can be considered when feasible, although scanning written records after the fact is generally more practical, especially when working in inclement weather without internet access, such as under a bridge in the rain.

Ultimately, diagnosis on the street is more based on a best-guess approach, rather than a rule-out approach, so clinical experience helps. Conditions that could affect owner compliance must be considered when prescribing medications, particularly in locations where theft and loss are common, and underlying conditions of the pet owner such as alcoholism or drug addiction can undermine medication schedules. Controlled drugs, or those with potential for abuse, should not be prescribed because of the high incidence of substance abuse among homeless populations,¹² but can be used to sedate the animals during a procedure. An emergency kit with appropriate drugs for treating adverse effects of vaccinations or anaphylaxis should also be available and include IV and SC fluid capabilities along with a portable miniature-oxygen-cannister system with a flow-metered mask (eg, Pawprint Oxygen Cannisters from Aeronics Inc). In the author’s experience, the oxygen cannisters provide approximately 15 minutes of oxygen at a flow of 1 L/min, making short-term sedation with dexmedetomidine safer for the patient.

Preventive care, including core vaccines and gastrointestinal parasite, ectoparasite, and heartworm testing and prevention, is similar to in-clinic care, but with nuances related to the challenges of pet owners living on the streets and unpredictable follow-up opportunities. High-compliance products are important, especially for long-term flea and tick control (eg, fluralaner) and, when appropriate, longer-term heartworm prevention with an injectable product (eg, moxidectin). Booster vaccinations are a challenge on the street and often fail to happen, even with a follow-up street clinic scheduled for that purpose. Recommended vaccination and other treatment schedules sometimes need to be modified since some pet owners living on the street may only be seen once, adding a risk-to-benefit ratio that must be considered.

Euthanasia, when the best choice, should not be performed in the street setting due to the distress it might cause to observers as well as the possibility of technical difficulties. Ideally, a referral arrangement would be set up with a local 24-hour hospital for potential euthanasia and aftercare. In addition, less urgent conditions may exist that require referral, necessitating the need for street medicine organizations to have funding set aside for additional care.

Spay-neuter resistance

In the author’s experience, significant resistance to sterilization surgery exists among the indigent pet owner population, even when the surgeries are offered at no cost. Various reasons expressed for turning down vouchers for free pet sterilization procedures include prospects for selling puppies and kittens, a desire for a female to “be a mother,” concerns about surgical risk, and undesirable changes in behavior. A lack of access to information about the benefits of sterilization for pets is likely a factor in this resistance to sterilization. In conversations with these pet owners, it can be helpful to point out that sterilization, on average, will increase a pet’s lifespan by about 18%, or 2 to 3 years, based on a large study of approximately 40,000 dogs.²²

Not dissimilar to incentives offered to people to encourage vaccination, such as those for COVID-19 during the pandemic, incentives such as grocery store vouchers may be effective for encouraging indigent pet owners to agree to sterilize their pets. Although homeless people may prefer cash incentives, these are not recommended owing to the challenges related to handling money securely and safely, especially within the inner-city environment. The cost of a cash-like incentive, even as much as $50 or more, will offset the future costs of managing the offspring of unsterilized pets. Incentive vouchers must be offered to all pet owners in a given homeless community to avoid unrest and dissatisfaction from those who initially agreed to sterilize their pet without such an incentive. Additionally, to solidify trust among these communities, any incentives should be paid promptly at a recheck examination following sterilization.

Creating a bridge of trust

With the appeal of providing veterinary care for pets of people experiencing homelessness, and the trust that is quickly established between veterinary providers and pet owners through such initiatives, a bridge is theoretically created whereby pet owners become more willing to accept medical or other health care for themselves since they are “here anyway” so “why not?” In the author’s experience, often this initial care is limited to history collection and physical examination, but such care opens the door for more extended care and potential referral, which are ongoing challenges on the streets. This one-health approach is being modeled at Colorado State University, where medical and social work students have joined veterinary students in weekly free clinics at a local homeless facility.²⁷ Case workers and mental health professionals are vital components of the outreach team because of the preponderance of mental health and addiction disorders among those living on the streets. Should a homeless person express thoughts about suicide, veterinarians speaking with these individuals can make an instant referral.

Veterinary case managers, a proposed new designation, are being trained by The Street Dog Coalition as part of a pilot program in multiple cities to follow up with homeless pet owners to address ongoing needs, both veterinary and nonveterinary, and provide reminders on upcoming preventive care.

For the first time, veterinary services are being offered by veterinary teams at Veterans Stand Downs, which are 1- to 2-day events put on by the US Department of Veterans Affairs providing free services, clothing, and gear for homeless veterans.²⁸ The Street Dog Coalition is working on a program called A New Found Life to place well-behaved shelter dogs with homeless veterans. Although service dogs have been placed with housed veterans through Zoetis’s K-9 Courage Program,²⁹ placing a shelter dog with an unhoused person would represent a major paradigm shift for animal shelters since there are usually rigorous requirements for potential adopters, especially in regard to their housing situation.

Ultimately, we are all in this together; stress, financial hardship, depression, suicide ideation, drug and alcohol abuse, and social dysfunction are not unique to people living on the street. Working toward an atmosphere of trust and nonjudgmental acceptance, the veterinary profession can lead the way for other health-care providers to create a safety net for those struggling to survive, and contribute to a sense of purpose for themselves and others, in a spirit of collaboration, passion, and promise.