Posts Tagged ‘Free healthcare’

Snowpocolypse. Snowmaggedon. Holy -Snow-Batman! Whatever you call it, the snowfall over the last weekend was historic. But something else was happening in Allentown while we were all watching from our windows and marveling at this weather phenomenon.

On Saturday morning, with 9 inches of snow already on the ground, the Warming Station in Allentown sent it’s overnight guests to the streets because they are only operational at night. If it had not been for a local pastor, these people would have been left to try to find a public building to shelter in, a business that was trying to remain open that would allow for loitering or an abandoned building that perhaps no one would be looking for trespassers in. And what about the people who were not at the Warming Station the night before who may not have known about the good Pastor and his open doors?  How could a Warming Station staff street their guests who would need a plan to endure another 10-20 inches of snow before the Station opened again?

It really made me think about whose ‘problem’ the homeless people really are.  Why are there only a few who will take responsibility or, dare I say, ownership over  ‘their’ problems? Are we societally too stoic, compartmentalized and self-determined so that we believe that those who face a blizzard alone and homeless should have thought about that before they ‘made all their bad choices’? Are we worried about becoming too involved, caring too much, knowing too much only to find that there are too many one-way, dead end streets in our society? Do we fear the futility that comes with knowing without being able to act?

It would be easy to blame the operators of the Warming Station for streeting these people in the face of an impending Blizzard. These stations are opened on the heels of a public health concern.  Who wants to have citizens of their town freezing to death on their streets? But it is also a public service based on the principles of justice and beneficence. So how could people be left to fend for themselves in these harsh conditions? Dr. Jim O’Connell, founder of Boston Health Care for the Homeless Program, and a Harvard trained physician issued guidelines on temperature associated health risks to the homeless. The bottom line is that while water freezes at 32 degrees, human flesh is at risk for freezing at just 40 degrees. Often the greatest risk occurs when the ambient temperature is warm during the day and then drops drastically at night. From a business standpoint, a warming station could say they don’t have funds to pay for staff to be there during the day. They don’t have a food source there. Maybe they don’t have permission to keep the building owned by the Park and Rec Department open during the day. There are a hundred other reasons that they could come up with and some might be true. But the truth of it is, it doesn’t matter. These are people and they needed shelter. Could there have been a solution? A work-around?

The gravity of this current snow situation for the homeless is likely not to be understood for some time. But with each challenge must come insight and solutions to minimize risk the next time around. First, is the issue of the Code Blue designation. The Code Blue designation is issued by Lehigh County Emergency Management when temperatures dip below 32 degrees. The Code Blue status is supposed to be posted on the Lehigh County Emergency Management website but currently does not indicate a Code Blue listing. Today is a high of 26 and a low of 9, certainly we meet criteria. ‘Code Blue’  isn’t a searchable term on their website and it is difficult to find any information about what this designation really means. Anecdotally, I can tell you that local shelters loosen their admission criteria and put people any where they can as a temporary measure. The most current listing of Code Blue places available on the internet is from 2014 and basically contains a list of local shelters. Shouldn’t this designation allow for other buildings owned by the City to remain open as a public health measure? And why is the temperature cut off 32 degrees when data supports danger starting at a temperature of 40 degrees?

Second, those who are in the business of providing shelter as a public service should be held accountable for their actions. Many of these shelters and warming stations receive monetary support from citizens, government, grants etc. who expect that they are providing the service of warming and shelter.  You are accountable to your stakeholders. Is the city of Allentown responsible for sheltering these people or are they relieved of their responsibility because they funded another entity to provide this public service?  Take the example of our local hospitals. Healthcare workers slept in the hospital and shoveled on-ramps on 78 in order to get to work because the hospitals take their responsibility of being prepared for patients despite weather or any other natural disaster. The hospitals require it and the healthcare workers abide by it because of their moral responsibilities to their patients. Another example is the accountability of disaster preparedness where organizations accept risk for the greater good. Successful organizations balance between risk and preparedness with the ethical principles of justice and nonmalifecence. These preparedness documents should be well thought out and easily implemented. Just as in disaster preparedness, when running a winter shelter, one must be prepared for winter weather.
Finally, there is the humanistic aspect. In times of trial when human lives and dignity are on the line it is ALL of our responsibility to care for those in need.  If you’ve accepted the public commission to care for the most vulnerable, you can’t abandon that post in the worst of times. At the same time, if you haven’t accepted that post in an official matter you aren’t absolved of your moral responsibility. This weekend in Allentown that is exactly what happened. Although not bound by grants or funding, Zion Church opened their doors to those most in need of sheltering from danger, just as they did in 1777 when they “housed” the Liberty Bell, keeping it safe from the British during the Revolutionary War (www.libertybellchurch.org).  Let it be a lessoned learned; that true responsibility comes from within.
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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.

The weather has always baffeled me. In a strange way, weather has a way of forcing you into the next phase of the year, ready or not. Saturday had temps in the 90s with humidity so high that it made my normally very straight hair resemble the before shot of an antifrizz hair product commercial. Heavy rains came Saturday night and just like that, Fall arrived. Football, crisp morning air, windows open.  

Last Fall, Brett and I attended our first Street Medicine Symposium in Boston. The Boston Healthcare for the Homeless Program has been the program that all others compare themselves to. It is a huge, well established program that has the most comprehensive programs, resources and street teams. The tentacles of this program seem to reach into all the parks, shelters, hospitals etc. To say we learned a lot would be a stupid understatement.  I recall having a conversation with Dr. Jim O’Connell, president and founding physician of the Boston program.  We were talking about funding (of course) and I said I was amazed at the multi million dollar budget of his program.  He inquired as to the budget of the DeSales Free Clinic and the scope of services. After I told him our annual operating budget was $15,000 he response was ” jeez, we must be doing something wrong if we need so much money”. We then talked about how we operate on limited funds. This is the attitude in Street Medicine – no matter how big or small your program is, fledgling or benchmark status, we can all learn from each other.

A unique feature of these conferences is participating in street rounds with the hosting institution. We really got to see how the pros get it done. I was rounding with a case manager who was looking for one patient in particular- John. She had not been able to find him for the last two weeks and was worried about him. We checked all the usual places that he hung out. We met his street friends who had much to tell us – except for where John was. And so our search continued.

It was about 6pm and downtown Boston was bustling with people leaving work. The streets and the crosswalks were very crowded, horns blaring, quick feet. At a particularly busy intersection, we began to cross just as we see a large dip form in the sea of humanity. As we approached, we saw that our lost patient- John- was right at our feet.  Wheelchair bound, he had lost his balance and tipped right out of his wheelchair and onto the ground. I was impresssed at the number of busy Bostonians who stopped to help him and make sure traffic would not hit him when the light changed to green. We scooped John back into his chair and moved him to the sidewalk. 

John was a rather imposing figure, both in size and in scowl. When you close your eyes and picture a chronically homeless man on a wheelchair, you are likely picturing John. Standing, he was most likely over 6 feet tall. He was wearing many layers of well worn and tattered clothing. He had on an old navy blue winter hat that was a little lopsided so only one eyebrow was showing. He was missing most of his teeth and had a rosy hue to his deeply wrinkled skin. He was not particularly friendly toward me and answered the case managers questions in a short and gruff tone. Yes he had been drinking. No, he didn’t need anything. No, he wasn’t hurt. Then she asked if he was hungry- and for a second, the fiercly guarded wall came down. He was hungry, and thirsty too.  He hadn’t eaten in several days. 

While the case manager went into a Panera Bread, I had a chance to talk to John (or attempt). I started by trying to figure out if he needed anything else since it seemed the peace offering of food had opened the door just a smidge. He told me part of the reason he had a hard time eating despite the available soup kitchens and food vans was that he had a peanut allergy. A severe peanut allergy. Imagine the great lengths moms across America go to in order protect their childreen from inadvertant peanut ingestion. There is even a service through my children’s daycare to find them a playdate with a child whose allergies match your childs ( think match.com but for kids with allergies). Before John, I had never considered what it would be like to have a food allergy on the street. I asked him a few questions about his peanut allergy and then, apparently, crossed the threshold of number of questions allowed.  

I had squatted down to talk to him. Being at the same eyelevel of someone who is wheelchair bound (homeless or not) is extremely important for leveling the playing field. Suddenly, John looked angry. He was nose to nose with me and yelled with a slurred speech, ” Do you reaaaaaaallllllllyyyyy care?” Pause. ” Well, do ya?!” I told him that I really did care. He looked away and muttered, “Well, I don’t know why.” 

There was they key to this whole interaction. Imagine wanting to be helped but feeling inside that you are so worthless that no one in their right mind should want to help you. Therefore, you prophylactically refuse the help because somewhere inside of you, you believe that you are protecting yourself from the inevitable. The dissapointment you will feel when the person decides you aren’t worth it and that they don’t care. Self preservation is a vital survival tool when living on the streets.

We walked with John to a location across town that he liked to hang out ( we had actually been there earlier that day looking for him). He was greeted warmly by his street brothers. A fleeting smile crossed his eyes (but not his lips). As we walked away, I turned back to see John breaking his sandwhich into four pieces – one for him and one for each of his street friends while they passed the bottle of newly purchased lemonade around. A reminder that the parable of the fishes and the loaves is lived every day on the street.