Posts Tagged ‘Healthcare for the homeless’

Laura, how come you never asked me about Islam?”

I smiled at him. I said because your religion isn’t a factor for me, no one’s deserves to be homeless, especially homeless and blind.

He says to me, “I have been thinking to myself, why is this white Christian woman helping a Muslim black man” he laughs. He then lowers his head and says, “when I came to America, America was asleep. It was a beautiful country, then 9/11 happened and it became so hard for me. ” We sat in silence for less than a minute he turns to me, “Thank you, you are a great communicator and I don’t know how I would ever get here myself. God bless you. ”

Our journey together is not going to be an easy one, we are making small steps every week. Until you have become homeless or ever tried to assist the homeless you will never truly appreciate simple things such as making an appointment with a specialist, getting a pair of glasses, getting unemployment, applying for an apartment….for these people it takes months to obtain any of this. The average individual simply makes a phone call…applies online…gets the information mailed to their house…where does a homeless individual get their mail? What phone number will be called? Who has an email address?

As a nurse I don’t think I have ever felt like such a patient advocate as I do right now in my current career

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Today I watched a woman and her boyfriend go “shopping” in our donations room….they have been wearing the same outfits for 2 weeks. They were so grateful for everything we had to offer. I was asked several times, “can we have this?” Every time I smiled and said of course..as they sorted through the items I heard them constantly say to one another, we don’t need that, leave some of those, this is amazing…

You see this couple had a rough past, burned the bridges with their loved ones, the only bridges not burned are through current drug users. They sought out help at a rehab. When they started dating they were kicked out of rehab…tossed to the streets. All of their belongings were kept at the rehab and they have nothing.  They didn’t want to speak badly about the rehab because they felt it had truly helped them. They are now staying in a winter shelter. How do we expect people to stay clean&sober? They fought the fight of withdrawal, found support and are put to the streets. I can’t imagine how hard it would be to stay clean facing the circumstances these people have to face. It’s very sad to me…we lack support in the areas that we need it most, for the people who need it and want it..

This couple, they told me not to worry, they found love and are going to support each other through this mess. I assisted them in getting clothes, hygiene products, nail polish…just so she could feel normal again…

And thank to the person who donated the Uggs…she was ecstatic, you would have thought she won the lottery as she screamed with joy. I wish you could have seen her face.

~Laura LaCroix, R.N.

The vastness of need can seem endless.  When Brett and I started the DeSales Free Clinic, we had some experience under our collective belts to try to guide the creation of something that would be both meaningful and sustainable.  As it grew, so did our awareness about the larger problems facing the homeless population. Things like personal safety, humiliation, lack of affordable housing and lack of institutional loyalty.  It became easier to figure out reasonable treatment plans that actually had a chance of working because the context of their lives were so much clearer.

At some point, we started to become aware of the needs of other vulnerable and disenfranchised populations that were all around us. Human trafficking victims.  Domestic violence. Veterans. We learned that recently released inmates are 12.7x more likely to die within two weeks of release from prison than someone else living in their same state (Binswanger, NEJM,2007).  I still sometimes feel like a young PA student at Midwestern University all over again learning about the people that we share our world with but know very little about.  It is like standing in a dark room with the door closed. Then, someone turns on the hallway light and you see a small bit of light spread over onto your side of the carpet. Who turned on the light and who is on the other side of the door? Do you crack the door open and peak quickly? Do you fling the door open and boldly shout “Who goes there?”. Or do you retreat from the door and figure whoever turned on the light, didn’t really mean for you to see it anyway.  I think of the door as status quo.  It is always there and it is always accepted both socially and professionally. These populations often give us opportunities to engage them. They flick on the light in the hallway to see what happens to the door.  But all to often, we choose to retreat from the door and maintain the status quo.  The door never opens. Soon enough, the light turns back off and all goes back to the way it was.  But sometimes, someone flings the door wide open and invites the light in. Sometimes the door is opened by a patient. And sometimes the door is opened by a provider.  As it turns out, the light, in fact, is hope. And hope is just about the most powerful thing two people can share. A patient of Brett’s commented that he let the light in for her for the first time. Perhaps it was hope for her but little did she know that her willingness to let the light in  provides an understand that allows the light to be shared with others and the status quo to be challenged.

 

 

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.

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