Posts Tagged ‘DeSales University’

Last week, I was sitting in a leadership training about effective communication. The instructor started off with an explanation of the ladder of inference. This ladder represents stages of thinking that one goes through, often subconsciously, to determine action or inaction after observing a behavior. When we observe something, we often reflect back on the scenario to make sense of it and in doing so, may not remember all of the details (or even have all of the details). Our minds will fill in the blanks, or infer, what is missing to complete the observation so that it makes sense to us.  We determine action or inaction based on this conclusion. The example given to us was an observation of a quiet exchange between two people which concluded with one person abruptly leaving the conversation and exiting the building. We, of course, came up with a variety of colorful, and sometimes even logical, explainations for what we saw and action that should take place as a result. Sometimes this process leads to workplace drama, other times the inference ladder could be applied to whole populations resulting in dehumanizing sterotypes.

As Brett and I were talking with an old friend this week, we realized that the inference ladder had injected it’s influence on our life in a way that we did not realize until now.  I have written before about the influence of an experience Brett and I had during my PA school education at Midwestern University in which both of us spent time at Hesed House in Aurora, Il providing healthcare for the homeless. It was a meaningful experience that lead to the desire to start the DeSales Free Clinic, and eventually, LVHN Street Medicine. In our minds, Hesed House was providing comprehensive care with tons of hours of accessibility from students and volunteers. When we set out a decade ago to open the DeSales Free Clinic, we modeled it after our recollection of Hesed House. In reality, our blueprint for the vision of the DeSales Free Clinic was not Hesed House at all, but rather, the inference ladder at it’s best. A fill-in-the-blank Mad-Libs version of what we had experienced paired with what we thought was needed for the patients. Turns out inference might not always lead to poor communication or office gossip, but maybe every once in a while, a service to a population who is often dismissed as a result of the same thought process. Tricky tricky little ladder, I’m keeping my eye on you!

In September 2016, Brett and I traveled to Rome for the canonization of Mother Teresa into sainthood. In an effort to save money, we booked a local flat through AirBNB and lodged just two blocks from the Vatican. On our way back one evening, we crossed St. Peter’s square and, after passing two armed guards stationed at a government building, made a turn onto a side street close to home. The area near the Vatican has become a safe space for the homeless to sleep at night without harassment from the police. The local homeless service providers who generously shared their time, experiences and solutions with us tell us that this is a result of Pope Francis declaring that these souls should be left alone and allowed to rest without disruption. And so, to some local surprise, the local police have backed off and allow for some peace and quiet. As such, it was no surprise to see a doorway inhabited by an elaborate cardboard-bag-bottle structure skillfully designed to block light, noise and provide an astonishing amount of concealment for the person who was likely residing somewhere inside the materials. What caught our eye, however, was an inscription scrawled on the marble slab to the left of this construction – LOVE NEVER DIES. We stopped and took a picture of this remarkable image wondering who wrote the message and if the inhabitant of this doorway agreed or disagreed with the statement. We continued onto our flat and retired for the evening. Each night, we saw the same cardboard-bag-bottle construction with the same refreshed inscription, and each night we wondered.

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Three days later, we were walking back from the canonization mass. Anxious to rehydrate (it was about 92 degrees fahrenheit), use a bathroom (400am -2pm is quite a long time!) and to escape humanity for a minute (a sea of 500,000 humans is enough to make anyone need a quiet (padded) room), we nearly missed him. Our doorway dweller was awake, sitting up below the inscription and working on an elaborate drawing. Bathrooms, water and silence would have to wait. We made our way through the crowd and introduced ourselves. George, a man in his 60’s, had primarily inhabited this doorway for the last 6 years. A fisherman from Sweden, he had somehow been land ridden for some ambiguous reason. His drawings were remarkable. He had two completed charcoal drawings and was half finished with another one. All of the completed pictures contained a series of objects that were rearranged or drawn from a different angle. We explained street medicine to George and he engaged us in an interesting conversation about his experiences, affirmed that he had a doctor (however we discovered an access problem- his doctor was in Sweden), and how the heat of this summer had been particularly difficult for him. But it was his explanation of his drawings that moved me the most. The wooden truck was his favorite toy as a little boy, the canoe was his first fishing boat. A child sized fishing rod and small scaling knife were important pieces of his happy place. A pot for smoking fish lead me into a detailed conversation about how to properly prepare and cook fresh fish (fascinating for me considering I generally avoid eating things that originate from under the water). He said he draws to keep himself out of trouble. But I saw something much different. His drawings simply represented the happiest time of his life. A time when he was a young boy, falling in love with fishing and providing for himself. Before he spent 45 years at sea, had broken relationships with his family and had ended up, well, here. We purchased one of George’s drawings which hangs in a place of honor for him in our home. While he never explained why he writes his message next to his doorway everyday,  he really didn’t need to. He retains a sense of hope that one day the tides will shift and he will find his way home again, perhaps to the place in the picture.
He agreed to take a picture with us (which you can see below) and thanked us for keeping him company. As we walked away, George asked us to promise not to forget him. Promise made. Promise kept.

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A few weeks ago, Lehigh Valley Health Network and the Street Medicine Program hosted two events with Dr. Jim Withers, a pioneer of street medicine in the United States, to raise awareness about homelessness to different groups in the Lehigh Valley. The first night was a small gathering of donors at a local country club with Dr. Withers as the featured panelist along with Brett and Dr. Motley, chair of the Community Health Department at Lehigh Valley Hospital.  It was a fascinating discussion about how street medicine in many cities has uncovered an ugly truth; that healthcare itself is very, very sick.  Often times the Street Medicine provider straddles two worlds. A world of middle class America and a world of extreme poverty and isolation. In terms of Maslow’s hierarchy of needs, we expect all patients to be functioning at the top of the pyramid in a place that Maslow defined as self-actualization. That is the place where people are achieving or are on their way to achieving their highest potential.  Because this is the basic assumption for all of those interacting with the healthcare system, it is no wonder that conscious or unconscious bias seeps in to our everyday patient interactions.  The traditional healthcare systems gets frustrated with those patients who just don’t or can’t follow through. We label them as non-compliant and design policies that allow us to dismiss patients from our practices after two no call no shows or after being late for an appointment a few too many times. Because after all, our clinical time is important and if we allow ‘them’ to be late then we are just enabling them.

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The homeless population and their interaction with the healthcare system is an example that can be applied to many other vulnerable populations who are expected to be functioning at the tip of Maslow’s pyramid. Domestic violence, gender dysphoria, substance abuse, financial instability and recent prison release are all examples of people are struggling to have their basic needs met. It was interesting to see and talk with the attendees at the conclusion of the panel discussion. Many of them have lived in this area their entire lives and never fully understood how and why this type of human condition was lurking in their own backyards. Perhaps the best part of the evening came from the country club bartender who spoke with me, Brett and Dr. Withers after the room had mostly cleared.  He shook our hands and told us that in his job, he listens to a lot of very boring presentations (and I believe him) but he was so grateful to have listened to this panel discussion.  He felt he had learned so much and went on to tell us about the homeless people he had known in his life and how he thought they may have ended up that way. Of all the people in the room, it seemed that perhaps the unsuspecting bartender had been one of the main benefactors of the event.

The following day, Dr. Withers gave grand rounds at the Hospital. Over 200 people RSVP’d to the event and the crowd was primarily full of short and long white coats.  At the conclusion of Dr. Withers discussion, a panel of currently or formerly homeless Lehigh Valley residents shared their stories of living on the streets, surviving on the streets and in our institutions and candidly shared how things could have been better.  One panelist has been unsheltered for over 9 years and shared that the Street Medicine team are the only people he knows that are not homeless.  This spoke to me particularly as I was reminded of the isolating nature of homelessness and the sense that the world can become ‘us’ and ‘they’ with seemingly very few bridges between. As I sat and listened, I noticed how absolutely silent it was in the room.  There was not a single pager ringing, phone buzzing or hushed side-conversation. Several hundred people who usually conversate all day were hanging on every single word these brave men and women shared.  I thought about how intimidating the room must have looked from the panelist table and that for years, the patients felt like no one listened to them. And yet, here we were, begging in earnest for them to tell us their stories. The power of this paradox is in its irony. Healthcare providers have an opportunity every day to listen to our patients stories. Not just the story of their symptoms. But THEIR story. We feel pressured to rush, to ‘work lean’, to make in through but in the end, that isn’t what anyone wants. Each time I see a room full of such talent hear the message of street medicine and the stories of its patient’s, I can’t help but feel the pull of a tide. That perhaps we are closer than we think to a return to the roots of good medicine and real connections with all of our patients.

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.

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.

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

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.