Archive for the ‘Uncategorized’ Category

Gift giving.  Tis the season for the imagry of Christmas presents under a carefully decorated tree or eight stacked presents to represent the eight nights of Hanukkah. Having small children seems to make the season especially charming. But admittedly, sometimes this season can be challenging for people who work in the homeless community. The contrast between the haves and the have-nots is often stark and blinding.  All providers and advocates have to find that delicate balance in their lives between doing the work and going home to a life that is in such contrast to the life of our friends on the street.

We recently introduced a ‘vulnerable population curriculum’ to the PA students at DeSales. We talked about homelessness (of course!), global health, refugees, human trafficking and spent a lot of time challenging them to think about what it means to be ‘vulnerable’ and how that affects health.  During a series of reflection papers, a student exclaimed that he liked these activities but they were so depressing- who knew of all the things happening in the world. For a moment (or perhaps longer), he wished to live in the world where he eyes were still closed.

His comments though, really made me think.  How is it that there are people who chose jobs in which they take on the burdens of others. A friend who works in Oncology gets asked often – “how can you work in that office! It must be so depressing!”.  Many clinicians have occasional patients who have a story that will stop you in your tracks. Their story tends to haunt you for a few days before enough ‘regular stories from regular people’ wash away the traces of horror you felt a few days before.  But what about people who take on the horrors and traumatic experiences of many individuals at the same time. I think about people like Mother Theresa or Jack Prager ( who has been doing street medicine since the 70s in Calcutta, India) or Jim Withers (father of street medicine in the US).  The things they have seen and heard, the grief they have shared with their patients all while maintaining sanity, faith in humanity and a wicked sense of humor (especially Dr Prager!).  And somehow, seeming to find themselves in the midst of the chaos.

The word compassion derives from com- meaning ‘together’, and pati- meaning ‘to suffer’.  I often interview candidates for PA school admission who describe themselves as ‘compassionate’. When I ask what they mean by this, they usually answer that they are caring or empathetic. It isn’t a completely wrong answer but it isn’t completly right either.  There is a difference between feeling sad for someone and suffering with someone. And frankly, one is more exhausting than the other because it makes us vulnerable too. I think that much of the work we do in street medicine and with vitims of human traficking calls on providers to suffer with another person. And honestly, sometimes it isn’t easy. Often what is spoken about ones experiences have never been said to another soul.  It is a fragile truth that often can begin to free the speaker from the guilt and shame that comes with holding a secret for so long. I think some people, like Jack and Jim and many others, have been given the gift of suffering. An ability to see a world that has been so cruel to people but still resolve in the hope that exists for each them.  It is in these examples that we look to find the gift of suffering within ourselves. Each relationship is an opportunity to do more than just listen and leave, but to share, survive and hope with our friends.

The Great Equalizer

Posted: October 23, 2015 in Uncategorized

Statistics surrounding the number of physicians pursuing MBAs always seems to baffle me. From a distance, I think about how much schooling a physician endures (yes, I do mean endure) and debt incurred. After some time in practice, there is a shift in some to seek higher levels of administrative purpose. Department chair. Service line coordinator. CMO. VP of this, VP of that. Acronyms that I can’t even describe much less understand. Sometimes it is hard to wrap my head around this pursuit of upward mobility. Traditionally physician assistants share a common philosophy: we see patients. We do it in a variety of ways, in a variety of locations. But most PA’s don’t graduate and consider upward mobility as part of their job satisfaction or career plan. While there have been more administrative positions being offered to physician assistants as they gain decades of experience, it is certainly not the norm in most hospital systems. Physicians, however, have different choices to make in this regard.

Over the years, many people have passed through the shelter and soup kitchen based clinics. Often their feedback is similar. This is the way medicine should be. No red tape. No coding. No drama. Just good, simple medicine. We don’t pay any of our volunteers and we don’t beg them either. It is the simplicity of providing truly patient centered care, without time constraints, bundled payments, matrices and check lists, that keeps them coming back. Our philosophy in the clinics is that we are all equal parts of a team. Just like our patient philosophy, everyone matters. If staples need to be picked out of the carpet, the task will not immediately be assigned to the person with the least number of initials behind their name. Folks who aren’t interested in such credential ambiguity usually don’t last too long. For a time, I thought of these Clinics as a great equalizer. Egos in check while the patients get checked. But this isn’t entirely true. Even in the Clinics, titles are still prevalent- doctor, PA, student, nurse, volunteer. There is nothing wrong with identifying yourself (and we must so that patients are clear about who is treating them) but we have to be honest that titles place a degree of separation between us and our patients and often as soon as the words leave our lips, we are trying to find common ground to narrow the separation.

Enter street rounds.

As mentioned in previous posts, most of the rough sleepers of the Lehigh Valley retreat into the woods. Safer. Discreet. Remote. Invisible. While some of the street rounds are done by the LVHN street team on the streets of the Valley, most of them are done in the woods and under bridges (with an occasional storm drain thrown in for good measure). Participants in street rounds have included many interested parties over the last year; none of which are more fascinating than administrators. I don’t dislike administrators. In fact, they are critical to the health care system and to giving real legs (and the necessary teeth) to out-of-the-box programs like Street Medicine. The administrators who have come on rounds knew first hand that to really understand programs and patients like these, you have to see it. And as the saying goes, seeing is believing.

The woods are really the great equalizer. During street rounds, everyone is on a first name basis. No matter what the title or degree held, status is check at the edge of the wood. Maybe the uneven terrain makes us feel vulnerable. Maybe it is the starkness of the humble camps and being acutely aware of how incapable of survival in these conditions we would be. But most likely, it is our street friends who share their stories willingly. The humanistic experience that makes you realize in real-time that we are more similar than we are different. They see the faces and hear the stories of simple unmet needs and complex social histories that lead to what they see. It truly and respectfully on the backs of these survivors that Street Medicine is deemed necessary.

Sitting on a tarmac outside of the Newark NJ airport, I am trying to wait patiently for my plane to take off. I hear mostly white noise as people are shuffling to their seats and stuffing oversized bags into small overhead compartments. I look to my right and see a recent DeSales PA Program graduate sitting a few seats away. In the midst of our boarding process, I hear words being shared about street medicine and homelessness to the unsuspecting middle seat passenger. In 6 hours, Seth could have her convinced to attend the 11th Annual International Street Medicine Conference with us.

 

While I don’t often spend much time reflecting back on progress over time, I find that preparing for conferences like these tends to send me back to a time when I knew less in both knowledge and people. Two years ago, Brett and I attended our first International Street Medicine Symposium in Boston. We had read so much about the world-renowned Boston Health Care for the Homeless Program (BHCHP) founded and flourished by Dr. Jim O’Connell. I had followed their website for years and had a visit to BHCHP on my bucket list for years. (Hey, some people sky dive, I visit homeless programs.) The opportunity presented itself for this visit with just a few weeks notice. Generous support from both of our sponsoring institutions (to let us go) and family (to keep our kids) allowed Brett and I to travel that Fall to Boston. It was the first time we were able to see a mature and robust healthcare for the homeless program and see first hand how something like that is grown and cultivated over time. Each member of BHCHP seemed to share the vision that had begun more than 20 years before. They were motivated, enthusiastic and committed. At a dinner reception after the first day, Brett and I met Dr. Jim O’Connell for the first time. He was genuinely interested in our small but eager programs. I mentioned that the DeSales Free Clinic has an operational budget of about $18,000. I’ll never forget his response. “You do all of that with $18,000? I have a multimillion dollar budget. It sounds like I have something to learn for you.” I was dumbfounded. You? Learn something from me? It sounded laughable ( and still does) but he was sincere. And a reflection of how all Street Medicine Programs are treated by their peers. This type of interaction has been repeated many times over as street medicine programs come from all over the world, once a year, to learn, share, eat, drink and be merry. Dr. Jim Withers of Operation Safety Net (Pittsburgh, PA) once told me that he thinks that people at this conference and his patients sometimes understand him better than his family. (True)

Now, we are heading to San Jose (CA) for this years conference. Our programs have grown exponentially since that first trip to Boston. So many ideas were illuminated, so many seeds planted. We are travelling with 8 other street medicine team members- 2 University of South Florida SELECT medical students, 2 DeSales University physician assistant students, 2 recent graduates of the DeSales PA Program, LVHN Street Medicine’s new case manager and new clinical coordinator. It is hard to imagine the life trajectories that can change when armed with the knowledge that comes from conferences like these. Brett and I sometimes joke that it feels like you are going away to camp. The time is short, the bond is strong.

Shared Luck

Posted: July 27, 2015 in Uncategorized

My path could have crossed B’s path long before they finally converged. Night after night, as the DeSales Free Clinic closed up for the evening, we were unaware that just across the street, B was settling in for a long, cold, nights sleep under an abandoned boxcar, in the parking lot of an abandoned nightclub. It was a harsh, cold winter and B had been ‘here and there’ as he would tell me in an attempt to find shelter. The boxcar, he said, wasn’t so bad. It kept out the elements and the ground under the boxcar was usually dry and not too cold. No one knew he was back there and the element of invisibility can be just as useful as a warm blanket when it comes to survival.

But I knew little of B’s hiding spot or of his story until one night, B awoke from a drunken sleep to discover his feet were tingling and extremely painful.  He was able to walk himself to the closest emergency room and was initially treated for frostbite. As luck would have it, it turned out that B needed much more that just frostbite rewarming. In fact, he needed urgent surgery to restore flow to his leg. The need for surgery wasn’t necessitated by the frostbite. The problems with his circulation were years in the making, but happened to make themselves evident to the hospital team during that stay.

B and I came to know each other as he started a road to physical recovery. He is a thin man who has aged well despite the things he has seen. He openly shared parts of his story over the 7 months that I came to know him. He was from New York City where he got ‘mixed up in lots of things’.  He spent over 10 years sleeping on the streets and surviving however he could. He battled addiction for many of those years and saw few ways out of his situation. His life changed when he met a man from Pennsylvania who ran a rehab and recovery farm in a rural area near the Lehigh Valley. He offered him a chance to start over and B took it. He was able to overcome his addiction and stayed on to work at the farm for many years as a peer mentor and advisor. Eventually, the farm closed and B was able to find employment at a locally owned grocery store. He worked there for nearly 20 years. He never missed a shift and seemingly took a lot of pride in becoming ‘part of the family’. I can see how it happened. B is an unassuming man with a narrow face, a pointy nose and gentle eyes. He is friendly and helpful. I can see how he became part of the fabric of many people’s lives over the years when folks did there weekly shopping, B was always there to bag, carry and check.

About a year ago, the small grocery store was sold to a large corporate chain. In B’s estimation, they one day realized that he was an awfully expensive grocery bagger. The original owners had allowed B to be paid more than your average bagger as a way of appreciating his loyalty and hard, honest work. But a corporate chain seemingly had no need for such expensive help.  He was fired and sent about his way. Over the next few months, he struggled to find more work. With the lack of income, he lost his car and then his house. He floated from couch to couch for as long as he could, but eventually, there were no more couches.

C.S. Lewis wrote a book called The Screwtape Letters. It is written from the perspective of a senior demon to his nephew who is new to the art of temptation. It highlights that the Tempter is often waiting until our most vulnerable moment to tempt us with the thing that we are most vulnerable about. It is a slam-dunk nearly every time. Addiction is much like this- often the weakest link in the strongest chain. The temptation of drinking his sorrows, or time, away was too much for B and he fell into an old (more than 20 years of sobriety) but familiar pattern of drinking his income away.

Once sober, B expressed no desire to return to any type of drug or alcohol use. In fact, he spent most of his time reading. I have never, ever, had a patient that read more than B did. He read every book in the entire facility. Nurses and staff were bringing in their favorites for him to devour. B was becoming the same type of staple that he was to his grocery family. Endearing, steady, calm. B was happy to have recovered from his medical issues, but he was now stuck in the facility. His insurance company had issued him a ‘cut letter’. ‘Cut letters’ are sent to the rehab facility when a patient’s insurance deems that the patient no longer meets criteria for rehab. It gives 48 hours notice to the patient and the facility- either discharge the patient or the patient pays out of pocket to stay. The ‘cut letters’ almost always come on a Friday and if you have a family or a home that you can go to, then a weekend discharge is not really a problem. But what if you are homeless?

The facility (as many do) was willing to allow B to stay if he signed over his social security check each month. Remember, he worked for 20 years, paid his taxes, paid into social security. They would give him $45 per month for other expenses. On one hand, it does keep the patient from being discharged to the street or a shelter. On the other hand, it prevents one from saving enough money to put down a security deposit, pay for a taxi to look for an apartment etc. B was grateful to have shelter, but he didn’t want to spend the rest of his days living in a nursing home.

I called a friend who is a housing specialist to assess B for any housing opportunities he might know of. I was thankful that he was able to see him and proudly declared that there just happened to be a single occupancy unit available in a quiet neighborhood that he could afford. I shared in B’s excitement at the good fortune and eagerly anticipated his departure date.

That was 4 months ago.

Getting subsidized housing is not straight forward. And who knew how many moving hoops there were to jump through, mostly feeling that you and the hoop were also on fire. The housing specialist got the ball rolling after the initial visit. But B needed documents- proof of this, proof of that, a copy of this statement etc. B had never had an email account, didn’t know how to do online banking or how to navigate the social security website to print out the precise document at exactly the right time so that it would be current enough but not too current. I, myself, had a difficult time navigating the site because I had no idea what I was even looking for. Once all the paperwork was finally in to the right person and approved, I did a little victory dance. Turns out , it was a very, very, premature victory dance.

The housing unit didn’t pass it’s annual inspection. While waiting for the landlord to make the improvements, the housing specialist quit and moved onto another position. No one exactly replaced him and so I was given the landlords phone number on B’s behalf. 4 phone calls and finally a returned call 3 weeks later. The building now passed inspection and B can move in- if he can physically get to the County Housing Authority in 4 days to sign paperwork. And then, of course, find a way to get to his new home by 2pm on day 5. I tried to find him a bus route but, as luck would have it, the LANTA bus website was down for multiple days. When it was up, I was convinced that my bachelor’s and master’s degrees were completely worthless because I couldn’t figure out how to get from point A to point B without seemingly visiting Toronto by way of Atlanta. Fortunately, a friend and homeless advocate, kindly rescheduled her own doctors appointment to take B to his Housing appointment (and ironically, also to the social security office because that damn paper STILL wasn’t adequate).  The night before he was to move into his new apartment, I was frantically trying to figure out how he was going to get there. He didn’t have enough money for a taxi AND  for the security deposit they wanted when he arrived. I had a free bus pass for him but, alas, the LANTA bus site was down. Again. As I began to blow a gasket on my couch at home, my husband leaned over and said, “Haven’t you learned by now? Some of our patients have the worst luck of anyone around. By helping them, you share their luck too.”

On July 1, I visited B for the last time at the rehab facility. I stopped in on my way to my other job in order to drop off a backpack for his belongings, bus tickets and a collection taken up to get him a cab. Later that afternoon, I learned that his taxi, had been 2 1/2 hours late picking him up though he had called them at 9 in the morning. I had presumed that he had eventually made it since he had not called me nor had anyone else who I had left my name/number with over the months of trying to help him. I had no way to reach him.

Last week, I received a text message from the original housing specialist. He had been out and about running errands and had seen B near the rental unit.  At the grocery store, of course.

Caterpillars are not particularly ferocious creatures. Slow and steady and according to my children, very hungry. I am not even sure that they make any noise at all. Or, come to think of it, have any teeth. They do their thing in their unassuming way and eventually make it to butterfly utopia. Silently and without bells or whistles, they make the world a more beautiful place. I have often marveled at the way passion can turn an otherwise quiet and unassuming human into a bull in a china closet. I am certain you have witnessed this phenomenon and it can happen to any of us. Once, while sitting in an ethics lecture some years back, a girl who I had never heard even speak suddenly found her voice and schooled the room about the seemingly double standard in the world regarding when life begins. Looking around, her point had not only been made, but her peers were blown away by the passion that was residing within her.

Advocates for many causes are much like the girl I just described. I remember a neighbor I had who loved animals. She always had a foster animal that she was rehabilitating for adoption. She would spend hours nursing the animal back to health. Once, I got up to go to the bathroom late at night only to glance out the window and see her sitting beneath a porch light picking fleas out of a sad lump of fur. I didn’t understand it then, but I do now. For some people, it is animals or organic food. The environment or breast cancer or autism or homelessness. World hunger, toxic waste or children in Africa. The cause is different but the root is the same. All causes need passion like this. It is what inspires other people to give two rats patooties about something they otherwise couldn’t care less about. I often think that I relate more to people who are passionate about SOMETHING (even if I fall into the rats patootie category about the cause) than those who are indifferent about EVERYTHING.

I am often asked how we do it all. I can see the look in people’s eyes as they ask the question. It is a third happy, a third bewildered and a third concerned. They know we have many clinics and homeless responsibilities. I myself work one full time job and two per diem jobs in addition to my obligations to the homeless. We have three children and other community responsibilities. I know why they are worried and why I am not. The answer is simple. I am compelled. I know that it is not I who is in charge of this master plan. Tenui nec dimmitam- latin for “I have taken hold and I will never let go.” This phrase reminds me to breathe easy, let it go (not the Frozen kind) and have courage.

Caterpillar roar.

I’ve never given a eulogy before. While preparing for his, I realized I really didn’t know much about him, but felt I understood him. The two words that best described him were courage and character. Not usually the first two words that come to mind when picturing a man who made his home in a drainage pipe for almost 5 years. He never left because he said, “It was a good spot.” In fact, none of the homeless providers knew who he was until the day he came into our hospital complaining of abdominal pain. At the time, it seemed like his life was finally turning around. He had a job. After months of trying, he got a job which required an almost 10 mile walk each way daily. He was saving his money and had an apartment picked out closer to his work so he could, “walk to it,” which always made be chuckle when he said it.

“Courage” describes him so well because the day I met him (in the hospital) was the day I told him he had a terminal illness and only a few months to live. He smiled his crooked smile that I would see so much over the next few months, shrugged his shoulders, and said, “Well, I guess that’s the way it goes….. What do I do now?” At first I wasn’t sure he understood what I just said so I repeated it and his reaction made me understand that he did understand, and simply had a degree of bravely rarely seen. He asked me what they would do with him after he dies. I honestly wasn’t sure so I asked what he would like us to do. He said all he wanted was a box with a cross on it but nothing else. He also told me he was Catholic but hasn’t attended church in about 15 years and wanted to know if it was ok to see a priest.

We told some of the local landlords about his situation and helped with getting an apartment for $250 a month so he wouldn’t have to spend his last days in the drainage pipe, no matter how good of a spot it was. He saw me at least weekly in the soup kitchen and was visited by our hospice nurse much more often in his new apartment. We also arranged for him to go into our inpatient hospice unit whenever he wanted, even if it meant his stay could last months, which isn’t the normal procedure for an inpatient hospice unit. He said he would stay out as long as he could so the people who were sicker than him could have the bed. By making that decision, it meant he would continue to struggle finding food daily, walking miles to different soup kitchens even as he grew weaker. I soon learned that his weekly walk to see me at the soup kitchen was the barometer he used to tell him when it was time to enter the hospice unit.

As time went on he grew so weak he could no longer make the walk to see me, was vomiting all food and drink, and was even having trouble getting around his apartment. Also, the heat broke in his apartment—in January—which he said didn’t bother him because he still had a bed and 4 walls, which is more than he had the last 5 year. With his nurses help, we convinced him to go to the hospice unit and he agreed. He wouldn’t go until he cleaned his apartment, packed up all his belongings, and took it to the shelter to give them to someone who needed them. We tried to talk him out of the strenuous task of cleaning when he was barely able to walk but he wouldn’t hear of it. The landlord was so nice to rent to him at such a low price he couldn’t leave the apartment dirty, he said. When I think of his strong character, I consider that for a man who had so little in life, and was now so close to death, his biggest concerns was for the sicker people in the hospital than he, the other homeless who were more in need of clothes than he, and not violating the trust of his landlord who first showed trust in him.

While delivering my eulogy I looked out in the full seats in the funeral home and was struck by how many people he brought together. All of his caretakers and an old acquaintance from high school came to say goodbye with a priest presiding in front of his beautiful box with a cross adorning the top. In the end, he got all he wanted, and we received a lesson of a lifetime.

-BF

Teeter Totter Tip

Posted: March 12, 2015 in Uncategorized

When I was a kid, the teeter totter both terrified me and excited me. We had an old school teeter totter at our playground which meant you could not only ‘bump’ someone sending their butt high in the air while they held on for dear life, but you could also ‘tip’ them by twisting your side of the teeter totter just enough that the torque tipped the other kid off into an unassuming pile of woodchips (which, by the way, who ever came up with that to be universally placed on children’s playgrounds?!?!).

Some time ago, I was sitting in my office at my University when there was a knock at my door. A well kept man was standing in the doorway. He had gotten my name from the Allentown Rescue Mission and came to me seeking my help. He was enrolled in classes at my University and found himself living in the Emergency Shelter at the Allentown Rescue Mission. He went on to tell me that he had been injured while working at a moving company several months ago. While he was receiving workman’s compensation, he was struggling to keep his car in good repair. It needed a $500 transmission and he had been overdrafting his bank account each month to try to put money toward the repair. Determined not to miss class, he had been driving to school going 15mph down a major highway with his flashers on several times per week. As we talked, I learned that he had been homeless for the last two years. Sometimes living in his car, sometimes living on a friends couch and recently, living in a shelter. He would save up enough money to rent a hotel room for the weekend when he had his children but he worried that he would not be able to come up with the money this month to do that. He seemed to be a man in on the verge of desperation.

As we talked, he told me of his attempts at getting help with housing, insurance and jobs. It always seemed that people wanted to pass you along to the next department, never really taking the time to listen. I offered to make some phone calls on his behalf to help him secure a bed in the shelter for a little while longer. He also seemed like a good candidate for some local rental assistance programs and I volunteered to call the local agency on his behalf. He looked genuinely greatful. As I racked my brain for any other resources and connections to help him, I inquired if he had told his professors or his academic advisor about his housing situation. He glanced at me and sheepishly admitted that he doesn’t tell anyone because he is embarrassed. As I wrote down some instructions on a business card, I couldn’t help but to comment that there is nothing wrong with him and that this situation does not have to define the rest of his life. I was saying it more as a statement than as a pep talk but as I looked up, I noticed he was crying. He went on to tell me that the last time someone said something like that to him was 2 years ago just before he lost both his mother and his father in the same year. The downward spiral had begun shortly after their deaths.

Hope. We think it is amorphous and invisible but it really isn’t. After meeting with him, you could see some optimism be restored because someone was willing to put themselves out there on his behalf. I made no promises of housing or prosperity, something I have learned to be quite clear about. But I could see that he wanted to be better than what he saw his life becoming.

It reminded me of a study commonly referred to as the Rat Park study performed by psychologist Bruce Alexander. The study looked at addiction behavior and how the environment affects addiction. The traditional rat experiment on addiction has a rat (or rats) in a metal cage with access to regular water and access to cocaine infused water. The rats inevitably chose the cocaine water and usually ended up gorked or dead from overdose. Alexander wondered what happened when you gave rats the same access to the drug but placed them in a supportive environment with all the wonderful things that rats would love to enjoy, including other happy rats. What he found is that most of the rats wanted nothing to do with the cocaine water. Though readily available, they chose the regular water and to have ‘fun’ in Rat Park.

So many of us are like my student and many others who wind up in the shelters and soup kitchens. Teetering. He had a job and a family. A house and a sense of belonging. But as things started to unravel, so did his supportive environment. I am not saying he was or is perfect- a concept that I find moot and boring- but I am suggesting that we live in a world where Rat Park is directly connected to the bare metal cage. Individuals end up feeling alone, embarrased, unsure of where to turn or how to get out. They forget that the two worlds are connected by a two-way street. For some, hard times represent a ‘bump’ but are lucky enough to keep their seat when family, friends and community support guide them to safety. The alternative?
Teeter. Totter. Tip.

Tonight, I was playing mommy referee mediating yet another squabble between by two daughters. They are 23 months apart and like most siblings love and hate each other with 150% effort.  While I am sure repeating myself over and over must sink into their brains somewhere, sometimes I bore myself with the repetition. After the one millionth melt down in the course of 45 minutes, I finally said “Girls! You are a mirror to each other! What one does, the other will also do! If you want to be treated nicely, be nice!” They kind of looked at me like I had three heads. But then started to smile, then giggle, then run off to play pretending to be each other’s mirror and see what they could make the other do in response.

It reminds me of a patient I saw last week for the first time. I am fairly new to one of our local nursing homes so I am sure the staff there hasn’t been notified for my love of homeless patients. That would be the reason for ‘ the warning ‘. I am sure the staff member meant it to be an act of comradery. Give the new girl a heads up. She went on to tell me that my new patient was homeless (followed by an eyeroll) and had AIDS (“of course”) and had the audacity to spend 20 minutes in the shower while she was waiting to start his treatments (sigh, huff, puff). “Good luck with that one!” she said. I thumbed through the 9 million un-useful pieces of paper that had accompanied the patient from the hospital and came across a psychiatric consult that stated the patient lacked the capacity to make his own decisions.  A rather big deal in the medical world that essentially means the patient lacks insight into consequences and can’t be trusted to make their own treatment decisions. It was also particularly relevant to this man since he had tried to sign out of the nursing home against medical advice earlier that day- something that is not allowed if you can’t make your own decisions. Trust me – that only added to his popularity.

I hung out with this patient for over an hour. We talked family, hobbies (a guitar player since age 12), his HIV mode of transmission (not IV drug use as the chart had stated), his medical history (he knew all of his providers names from his previous residence and their phone numbers), wishes and concerns. I asked him about the psychiatric assessment to which he responded “If you’re and asshole to me, I’m an asshole to you.” He went on to describe the interaction with the doctor and how he knew what to say to make ‘that dude disappear’. “It’s really not that hard to be left alone. People don’t want you and so you don’t want then nether.”

His interactions with me were far different than what had been described or documented in his medical chart. There are many reasons for this to have been and I don’t presume that it is all chalked up to my comfort talking about things that, for many providers, are uncomfortable. But I do think that we can become somewhat childish in our interactions. The patient throws up a barrier, then we throw up a barrier. Then the patient pushes our buttons, then we retreat from the interaction. And before you know it, this relationship is going nowhere. And the patient will soon be “non-compliant with a history of multiple no call/no shows”.

Why? Just look in the mirror.

~CF

We have been experiencing extremely cold temperatures over the past week, with the early mornings and evenings below 0 degrees. There is obvious risk of severe injury and death for our patients who choose to stay outside. We always attempt to meet them on their terms and respect the decisions they make, but first try to bring them in to safety. This was the goal when I arrived at Safe Harbor at 8:00AM- we needed to go to the camps by the river and try to get those folks to come in with us for a meal and a warm, safe place. The parking lot around back also serves as a meeting place for the guests to congregate but mostly smoke. After I pulled in, I got out of my truck I was greeted by one of the residence, “Hey, are we doing that homeless thing today?!?” The initial thoughts that rushed through my mind were, “What homeless thing,” and then, “Wait, aren’t you homeless (which of course he was)?” At that moment it occurred to me that the manner in which we carry out street rounds is so inclusive, that the area homeless are beginning to feel a part of it and are making it their own.

The way we perform street rounds varies from day to day based on the locations and the people we are going to visit. At times it’s better to have a small group- usually myself and at least 2 other guides. When we go out around Easton the mood is much different. Tyler, the Director of the large area shelter, Safe Harbor, is extremely well known. Almost all of the people we come across are either known to Tyler or know of Tyler. Because of this familiarity, when we travel around Easton my goal is to be more inclusive. Helping those most in need is difficult and requires full community involvement. Sometimes, the person in need feels alienated from the community. When the situation is right, we’ve found it to be extremely effective to bring the community with us to welcome them. When this happens, the community takes ownership over all of its members, and the previously alienated member feels less that way. There are times when we set out with 4 or 5 people on street rounds. As we visit various camps, we ask the homeless to join us on street rounds culminating in a trip to Safe Harbor for food, shelter, showers and even job assistance. Sometimes we return with 10-15 people. It is this approach that led this resident of Safe Harbor to feel, and rightfully so, that he too was an outreach worker and despite his current situation in life, he is still valuable enough to give back to those less fortunate.

When we set out this morning, I thought I was part of the street medicine program, but as we approached a tent with two very cold people sleeping inside and the same resident yelled from the outside, “We are the homeless posse here to bring you in!” I knew what group I was really working with that day. And we were much stronger than any medication in my backpack.

~BF

Whew.

Remember when you were in middle school and your parents sent you off to camp for two weeks for the first time? Personally, I dreaded that day. Two weeks seemed so long. And. let’s face it,  there were an endless number of spiders that could be encountered in 14 days. But off you went and when you returned, you were different. And suddenly, you had lived more in those 14 days and learned more about life, yourself, spiders, archery and basket weaving than you could ever have imagined. Multiply that by a gazillion, and that is what the first three months of full time street medicine in this household has been like.

As you may remember, Brett became full time street medicine on October 1, 2014 as a result of a grant from the Pennsylvania Department of Health. The support and the rate at which the Program has been growing in 12 short weeks is baffling, even by my standards. At the start of the Program, there was a shelter based clinic (Safe Harbor- Easton, PA) and a soup kitchen based clinic (St. Paul’s- Allentown PA) in addition to the separate (but closely related) DeSales Free Clinic at the Allentown Rescue Mission.  In three months, there are now street rounds twice per week – one day in Allentown, one day in Easton, a new clinic at the 6th and Chew St Winter Shelter, involvement of medical students, internal medicine residents, development of a homelessness screening tool, ground work for the opening of new clinics in the Ecumenical Soup Kitchen (Allentown), Salvation Army Hospitality House (Allentown) and New Bethany Ministries (Bethlehem). Not to mention the training for the new Network wide electronic medical record, meeting quarterly requirements of the grant and endless other tasks. In addition, I and DeSales University have taken to a new project by opening a clinic at the Truth Home for Women (Bethlehem) which provides free medical care to women who are recovering from human/sex trafficking.

I have had some time to reflect on these last few months during a much needed break from my teaching responsibilities. However, all that time I envisioned playing board games with my kids and organizing closets were erased by the passing of my dear uncle, the hospitalization of our 7 month old son (who is back to blowing raspberries and trying endlessly get his toes into his mouth), the declining of my most favorite sassy lady- my 92 year old Nana and a slew of other unforeseen life events. In those wee hour moments while rocking a sick baby back to sleep, I get my clearest visions and thoughts.

Life itself is without protocol. I remember being a PA student desperately trying to grasp the concept of electrolyte replacement and management. I remember begging for a protocol. Yes, I know protocols are really just suggestions. Yes, I know we treat people and not number. Yes, I understand that every case is individual. BUT GIVE ME THE PROTOCOL. Mostly, I thought, so I don’t kill someone out of my own stupidity. I needed place to start. Homeless medicine is an amorphous area of medicine. Most people who start out in this field are drawn to the social justice of it all, the simplicity of the system. But they are nervous, scared even. It is so far outside of how we normally practice medicine. Think of a typical office visit- there are front office staff, there is a scheduled appointment, there are people to room the patient. You see the patient and practice within well defined (mostly) evidence based standards of care. You fill out a bill, maybe write out a prescription that will need a prior authorization. Which will then be denied requiring you to either spend an hour on the phone arguing or change the prescription. It may be a pain in the butt, but traditional medicine has structure. It has protocol.

As we are training new providers to volunteer, open clinics and screen patients, I am reminded that this new way of thinking about medicine can invoke a sense of agoraphobia. There are no walls. No documented peer-reviewed standards of care. No protocol. In fact, it is the very opposite of protocol. It is creative, sprawling, think-outside-the-boxy, just-because-its-never-been-done-doesn’t-mean-you-shouldn’ty. This is the origin of the (my) addiction to street medicine.