With a chart in one hand, Dr. Stephen Parks raised four fingers on his other hand and sank wearily into a donated office chair at the Brandon Outreach Clinic.
"That's four new patients I've seen tonight," he told two of his physician assistants who volunteer with him on Wednesday, the only night the clinic is open.
Granted, none were as tragic as the little girl who once came in with a foreign object imbedded in her iris, requiring surgery the next morning to save the eye.
Or the gaunt man who had ignored the pain in his throat until it was so bad he couldn't swallow liquids.
Or the woman with hyperthyroidism who Parks insisted be hospitalized immediately. Had she waited another six months before seeing a doctor, "she probably would have died," he said. On this night, it was just the normal, heavy evening flow of patients seeking medical help. For free.
"Good in one way," Parks said. "Bad in another, in that there are people who need to be seen."
That's a dilemma the clinic grapples with as it grows and the economy withers. The more needy people the clinic helps, the more help it needs to operate three days a week.
Since treating its first patients 19 years ago, the Brandon Outreach Clinic has provided free primary health care to people who have no insurance or don't qualify for Medicaid but have an income that falls below 200 percent of the federal poverty level.
Now in its second home — a building on N Parsons Avenue that it rents from the county for $1 a year — the clinic treated 1,532 patients in 2007 and helped secure 8,000 medications for them free of charge. That's almost a 50 percent increase over 2006.
"They are a lifesaver, really, for a lot of people like me," Laura Stone, 43, said as she picked up prescriptions for high blood pressure and diabetes, the two most common conditions among the clinic's patients.
"When you're in that 'in-between' — you make too much money for Medicaid but not enough to afford insurance and medicine — it's a miracle."
Yet the miracle is getting a sobering dose of reality. In January, Quest Diagnostics stopped offering the Brandon clinic and other similar Florida facilities its lab services for free. Instead, it requires patients to apply to the company's national financial assistance program, which evaluates need case by case, with stricter guidelines to waive all fees.
If Brandon Regional Hospital had not agreed since to process some blood work for free, clinic executive director Debbie Meegan said, "We'd probably have to close our doors. We wouldn't have been able to absorb all the costs."
Still, the change has taken a toll. The clinic was forced to hire a part-time clinic coordinator to draw blood, prepare the samples and transport them. Tests the hospital can't perform are being sent to an outside lab. The bill the first month was $1,600 — a figure Meegan hopes can come down to an average of $400 with discounts and negotiation.
"And we have a budget that can spare about $50 a month, so we'll have to see what we can do," Meegan said.
Funded entirely by community donations, the clinic already spends the bulk of its $10,000 monthly budget buying medicine to supplement donated samples and paying four part-time employees who often stay far beyond their scheduled hours.
While two case managers screen patients for eligibility and steer those who don't qualify to other agencies, volunteers fill out hundreds of applications to 30 pharmaceutical companies that offer free prescriptions.
The clinic has a core of about 15 nurse practitioners and nurses who volunteer, as well as two pharmacists and a large network of area specialists who treat patients for free in their offices once a clinic physician refers them.
Yet for years, the Wednesday night duty has fallen on the shoulders of Dr. Parks and two other area physicians — the only ones who regularly donate their time. Because Florida law recently changed to grant "sovereign immunity" to volunteer health care providers serving patients who meet the same income requirements as the Brandon clinic's, Parks hopes that malpractice fears will no longer be an excuse.
"If all the primary-care physicians in this area volunteered just once a year for two hours on a Wednesday night, we'd be all right," said Parks, one of the community leaders who started the clinic. "You don't leave here tired."
More often, he's moved by the emotions of patients, like the woman who broke down in tears when he told her the medicine for her condition would be free.
Then there's Anne McBride, 63, and her 49-year-old husband, David, who makes $17,000 as an upholsterer. Six years ago, they hoped to barter his services to pay for surgery on her heel spur that had grown to the size of a pingpong ball.
The orthopedic surgeon explained he could do it for free if they qualified through the Brandon Outreach Clinic.
Ironically, during a follow-up visit a few years later, Anne McBride suffered a heart attack at the clinic, which rushed her to the hospital and has since provided her with heart medication at no cost.
"They are the nicest, the kindest people, who treat you with dignity and respect," said Anne, who drops a $20 bill in the clinic's donation box when she can spare it. "Back when I could afford to pay for my medical, I was never treated as well as I am here."
"It shouldn't be any other way," he said.