“Mr. Schwartz, where do you get food to eat,” I ask? “Well, it is interesting that you should ask,” he says. There is a Donut shop near where I sleep and at night they come out of the back of the store and bring me the extra donuts and usually a hot coffee.” “Sometimes, though, I have to go through the garbage and look for food”. “You know, I’ll find half eaten sandwiches in there.”
Mr Schwartz is a 53-year-old man. He is an accountant by training. Now he lives on the street and earns his money by collecting recyclable bottles. He was once married to a woman, Alice, for more than 20 years but just a few years ago she got sick with metastatic breast cancer. He started to take longer and longer absences from work to care for his dying wife. Her medical bills started to pile up. They liquidated all of their assets to help pay for the life-prolonging medications. He lost his job and soon the money ran out. Alice died. He lost his apartment.
“Mr Schwartz, where do you get your haircut?” I asked. “Well, it is interesting that you should ask,” he says. “There is a woman in the neighborhood who walks by me once in a while and instead of handing me money, she takes me to the local barber shop and pays for a haircut; she is a very nice woman.” “Mr. Schwartz, how do you shave?” I asked. “Well, it is interesting that you should ask,” he says. “Throughout the day I look for change in telephone booths, once in a while I’ll find a couple quarters. I’ll take this money and buy a disposable razor.” “And then where do you go to shave?” I asked. “I shave in the bathroom at Macy’s around the corner from where I sleep. There is a very nice bathroom there and the workers don’t seem to mind.”
Mr Schwartz came to the hospital today because he was weak, just hasn’t felt right for the last month. He tells me he is more tired than usual and has no appetite. “Food doesn’t appeal to me anymore,” he says. I start my examination of Mr. Schwartz simply by observing him. A sheet is pulled up to his neck, yet I notice that his eyes are sunken, his temporal muscles are wasting, I can make out every curve of the bones that make up his face, which is tanned from the recent sunny days and gives him the look of a healthy man. His silver hair is neatly combed to the left. His teeth are unusually white for a homeless man. I listen to his beating heart, no signs of an abnormality. I place my stethoscope on his back and ask him to take a deep breath; I hear the whoosh of air filling his lungs. I listen to his bowel sounds by placing my stethoscope softly on his sunken abdomen. I hear the usual gurgling of the intestines. I push my fingers into his right upper quadrant where the liver and gall bladder sit. This does not elicit pain. I pull down the sheet to expose the rest of his body. I look at his skin, which is strikingly a shade of yellow; somewhere between mustard and a banana peel. “Mr. Schwartz, when did your skin turn so yellow,” I ask? “Its been like this for about 2 months.” “We call this jaundice,” I tell him. It is caused from high levels of bilirubin in the blood. Mr. Schwartz, I think we need to get you a CT scan tonight to look into your abdomen to see what is causing you to feel so weak and changing the color of your skin. I am worried for what we will find.
“Mr Schwartz, how did you get here tonight,” I asked? “Well, it is interesting that you should ask,” he says. “I took the 7 train to Grand Central, then transferred to the 6, and walked from 26th street.” “Yes, Mr Schwartz, but how did you get here tonight if you have no money,” I said. “Well it is interesting that you should ask,” he says. “I told the police officer that I was going to the hospital and he let me get on the train for free.” That was nice of him, I thought to myself.
After one hour, Mr Schwartz returns from the CT scanner and is back in the treatment room. I access his scan on the computer and start to scroll through it. Just as I feared, there is a mass in his abdomen that is causing an obstruction leading to elevated bilirubin in his blood – the cause of his yellow skin.
“Mr Schwartz, I have to tell you something, we’ve found the cause of your weakness, poor appetite and yellow skin.” “Yes,” he says. “You have pancreatic cancer,” I say. “Well, isn’t that interesting,” he says quietly.