Posts Tagged ‘cold weather’

Nameless. Faceless. Invisible. It’s estimated that during the life of a homeless individual in the United States, many go up three months without being called by their name. The physical and social barriers between the housed and the unhouse are immense. For the homeless, it can seem to be an endless maze of closed doors. Like the old rat experiment from my Introduction to Psychology course- teach the rat what to do and what not to do by shocking it with a quick zap at deter unwanted behavior. For the homeless, they stand too long in the doorway of a business- zap! They go to a doctor’s office without insurance – zap! They ride the bus for too long- zap! Nowhere to go, nowhere to be and no where to feel safe.
But what happens when these souls pass on from this world? Most of the bodies of our friends who have lived their lives on the streets will remain in the county morgue waiting for someone to claim them. Usually no one comes. Unclaimed and unnoticed even after death. Most are cremated and buried in an unmarked grave, unceremoniously passing from the land of the living to the land of the dead. No memorial service, no sign in book, no slideshow of memories to cherish. Even the cause of death seem somewhat generic. The majority of the time the homeless who die on the street have died of “natural causes”. There’s no family to request an autopsy or discussion as to why or how someone died. They just simply die. The injustice against these souls does not end at the moment in which they take their last breath. Over the last 11 years, I’ve had the privilege of knowing many of our rough sleepers in the Lehigh Valley. Some have resided outside for more than a decade, others have floated between the streets, shelters and single room occupancies that scatter our cities. My experience has taught me their lives are anything but forgettable. Their survival to the moment in which they left this world is nothing short of remarkable. Many of our street friends have endured things that no human should ever experience. Abandonment, untreated mental illness, an astounding amount of physical and psychological trauma. And while each of us, homeless or housed, have undeniable autonomy over our choices, we cannot ignore how previous experiences affected growth, development and decision-making capacity of those who are unsheltered. They have taught me and those who have shared their lives with them the remarkable resilience of a person and how a community of strangers can grow to love one another when they share each other’s burdens. They are some of the funniest, kindest and truest souls I have even known who had a way of sharing their reality with me so I understood their wisdom.
As we ring in the beginning of winter this week, many cities across the United States remember those men and women who have died on our streets with a memorial service. So that their lives, even after death, can attempt to have some humanism attached to it. This year, a memorial wall has been erected in downtown Allentown. Located at 707 Hamilton St so that all who pass by will remember that the Lehigh Valley is not insulated from the harsh realities of homelessness and the fact that some of our own citizens die while struggling with homelessness. It is an attempt to remind us that we are all connected. The seen and unseen. The named and the nameless. So while we gather with those who we hold so dear during this holiday season let us remember those who passed in silence and offer them some compassion, some memory, and some honor.

“The woman declared that she was all for the building of a drug and alcohol rehab center next to her city apartment except that the proposed height of the building would cast shade on her kale plants and ruin her plants.”

Portland, Oregon was the host of the 2016 National Healthcare for the Homeless Conference and Policy symposium.  I found it to be a fascinating mix of liberal residual hippee mentalities mixed among upscale microbreweries.  A blue city residing in a largely rural red state. The first thing that struck me about Portland was how clean the city was. It’s beautiful to look at with its detailed architecture, Mount Hood peering over you in the background and the Willamette River hugging some of the neatest reformed parts of town. Freshly potted plants sprinkle the windowsills and front door steps of many residential and commercial properties. One afternoon I watched teams of volunteers artistically arrange flowers and potted plants in fancy designs in a local square just for the viewing pleasure of the many young professionals who eat their lunches on the squares surrounding steps. In general there was a sense of calm in the city.

But there was one obvious difference that somewhat shatters the beautiful façade of Portland. Every 6 to 10 feet I encountered a person experiencing homelessness. A man, a woman, a child just sitting on the street. Some of them were clearly high, but many of them were not. One woman sat with a pad of paper and pencil in her hand but was stuck in a catatonic state of waiting for inspiration.  Some of them were panhandling, many of them were not. Children were coloring while their parents made signs displaying their person plight. Many people were laying with their pets. The thing that struck me every day was that for the size of Portland, the number of homeless is unbelievable. Most numbers estimate between 3400-3600 people sleep on the streets of Portland every night. The lack of affordable housing and the lack of enough shelter caused the governor of Oregon to declare a state of emergency which allows homeless to sleep on the street safely without being disrupted by police, business owners or residents. The city has seemed tolerant of this and understanding of the fact that there is simply no where to shelter all of these people.  It does beg the bigger question though.  Why are there so many?

It seems that no part of the city with has been spared by number of visibly a visible homeless. During our travels, we took an informal poll. People working at donut shops. our taxicabs driver, local lifetime residents etc. We simply asked “Why do you think there are so many homeless in Portland?”   Interestingly they all gave the same answer. They thought that because Portland was such an understanding and homeless friendly community, the people (particularly youth) were seeking out Portland as a counterculture experience. There is a pervasive feeling that these that the majority of the homeless in Portland wanted to be homeless for the experience. While many of those that we informally polled recognize that the legalization of recreational marijuana probably his added to the appeal of coming to Portland, none of them could say for certain the size of that effect. The locals seem particularly bothered that there were so many people with seemingly no end in sight. While they admitted that they felt ‘bad for the people’, they were relatively unsympathetic because they felt that this was a situation that has occurred by personal choice. When I attended a breakout session with people representing homelessness from all over the state of Oregon, I told them what the locals told us about the homeless problem in Portland. I asked if they felt that it was true; that there was a counterculture experience occurring and Portland happen to be the perfect place for it to occur. All of those representing Portland on the panel adamantly denied that any of what the common feeling was true. One CEO of a local if you federally qualified health center commented that while the summers are mild, the winters are very cold and rainy and no one would choose to be homeless and stay in Portland. I would say the same for people who are homeless in New England, in Pennsylvania, in Michigan. Many people endure these harsh winters and yet they don’t leave (which has puzzled me for years). There’s no migratory patterns for the homeless to fly south for the winter. While the truth likely lies somewhere in the middle of these two polarized viewpoints, this creates a particularly large problem for philanthropy. People do not donate to a cause in which they feel the misery of poverty is by choice. Frankly, the sympathy factor goes way down and when there’s no sympathy there’s no money. Perhaps some of the most important (and challenging) steps that Portland must take is changing public perception. Porland seems prime for the picking to lead the country in inovative solutions to minimize homelessness.  A combination of finances, a youthful open minded population with well-established social and healthcare services. I look forward to watching this city’s story unfold.  Press on Portland, press on.

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

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.

Yesterday afternoon, a few of my co-workers and I were walking to a picnic held on the DeSales University campus. We were admiring the beautiful weather and the beautiful surroundings. Despite my love for the urban and rural homeless population, I have to admit it is a quiet retreat to spend time on this beautiful campus of rolling hills and beautiful fields.We noted a tree that was already changing it’s leaves. This launched a whole discussion about how everything is in a hurry- A.C. Moore already has Christmas decorations for sale and emails are jamming my inbox with taglines reminding me how many Fridays are left until Christmas. I, for one, have never really enjoyed winter. If the weather could stop at late October and blend right into April, I would be happy. The prediction for our area this year is another unbearably cold winter with higher than average snowfall. Putting my own last winter-related, generator-finding-polar-vortex-enduring PTSD aside, I think to the other work in my life.

It was a Sunday at the end of February 2014.   Brett’s cell phone rang and it was Jackie, a parish nurse who works with Brett at the Soup Kitchen Clinic. She was calling because she had a patient with her who was desperate to find someone named Corinne who normally takes care of him. She wanted to know if Brett knew who this Corinne person was. Much to her surprise, he passed the phone to his right and she got her answer. It seemed that Kevin* had been asked to leave the homeless shelter he was previously staying in. He had violated one of their rules and as Kevin said, “That was that.” He was out of medications but more importantly, he was out of shelter . The only other place to find shelter was over full and Kevin had been denied entrance the prior two nights. The temperatures were drastically low and he was scared and cold. He had only been able to take the belongings that he had near his bed. All of his items in storage, he told me, were discarded. Imagine the attachment you would have to your belongings if you could count all of them on your own two hands. More concerning, Kevin suffered from incontinence. Not having a reliable place to use the restroom and clean clothes to change into worsened the situation.

Kevin has been my patient for the last two years. He comes to the Clinic religiously every Tuesday for a blood pressure check. The blood pressure check almost always reveals more information about his week, his life and his other medication conditions. Despite his chronic incontinence, he always smelled like cologne. Kevin was compliant, he was never late for an appointment I had set up for him and he never ran out of his medications. He is talkative, polite and wonderful with the students. He had often told me he liked helping the students get their education. The students felt responsible for Kevin, but Kevin also felt responsible for the students.

Kevin and I agreed to meet on Tuesday. I went to my PA students and explained Kevin’s situation. Most of the students knew him from the Free Clinic and were deeply saddened to think of him sleeping on the street. I could see it in their faces- homelessness just got real.

Being that Kevin is a very tall man, finding clothes for him would be difficult. But the students rallied and came up with clothes, toiletries, snacks and other things they thought he would need. I arrived to meet him a few minutes early. In a strange change in weather, the polar vortex had given way to an unseasonably warm that day with a high of 62. I had not even worn a coat as I walked from my car to the building and I passed a few overzealous locals in shorts and tank tops. A few minutes later, I looked out the double glass doors to see a man dressed like the Abominable Snowman. He was struggling with the heavy doors and as I walked closed to help him, I realized it was Kevin.

Everything he owned was literally layered on his body or crammed into a messenger bag that was ripped down one side. Over the course of 10 minutes, he removed from his body 4 winter hats/hoods, two pairs of gloves (both ripped), a puffy winter coat, a leather jacket, a windbreaker, two sweatshirts, a button up collared dress shirt and a long sleeved t-shirt. He had on three pairs of pants, all of which were soaked with urine. What bothered me more than his layers, was his facial expression. Minimal eye contact, soft voice. No smile, no light hearted upbeat Kevin. The Kevin was lost, buried in the pile of clothes sitting beside him. A sadness filled his eyes. He told me he was so embarrassed for me to see him this way, embarrassed to walk the streets literally wearing everything he owned. He didn’t know what to do, where to go. He was desperate. Then his phone rang and it was his mother. She wanted to talk to me. I could hear it in her voice. She begged. She pleaded. “Find him somewhere to sleep tonight! Please! Why isn’t there anywhere else for him to go? Where are all the other people who are homeless?” Her questions were valid. Her frantic tone of voice was justified. Her disbelief that we have nowhere to put our homeless at night. I apologized, I justified, I rationalized, I validated. But in the end, I had no answers.

Then it was my turn to beg and plead. Could he come home to her? Were there resources for homeless in her town? Could she think of a family member, a friend, anyone who would take him in? All the answers were no. And while she wouldn’t elaborate as to why, I could sense that her answer was non-negotiable. There was no answer for Kevin that night. He had nowhere to stay and nowhere to go. It was gut wrenching. As a health care provider, I felt horrible. As a mom, I cannot imagine laying in my bed at night wondering if my son was sleeping outside in the cold. As a friend, I felt helpless. I could work no miracles that night. He slept outside behind a YMCA and waited for another day.

Eventually, we were able to convince the shelter that had asked him to leave to reconsider their decision. Kevin was permitted to return to the shelter and has been diligently working on filling out government paperwork, attending doctor’s appointments and applying for housing. Last week, he proudly reported that he had work with a local resource to update his resume and had interviewed for three jobs. Progress was being made and I am so proud of his recovery trajectory. As summer fades to fall, I know that Old Man Winter is waiting just around the corner. He lurks and just when you have almost forgotten the bone chilling cold that makes you want to pack up and move South for good, he snaps you back into His frosty world reminding me that “Walking In A Winter Wonderland” could have only been written by a person who was housed.