Posts Tagged ‘homelessness’

Street Medicine has rapidly spread to become a global movement with over 100 programs worldwide on 6 continents. As the Street Medicine Institute prepares for the 13th Annual Street Medicine Symposium this October in Allentown, PA, it’s right to explore why this movement has taken hold and how this innovative healthcare delivery plan has inspired hundreds of overworked medical providers to put on a backpack and work more long hours for free outside the traditional medical establishment. Although the explanation I put forth is in no way comprehensive, may it serve as an offering to explain the “core” of what those associated with the movement are experiencing by going to the people.
One of the first lessons taught to medical providers in their education is not to get emotionally involved in “cases.” This means not getting too close to patients—no crying, no hugs– and not experiencing what they’re experiencing. It’s become a matter of professionalism, that’s it actually UNPROFESSIONAL to care. When people come to us in the midst of some suffering, they are reduced to becoming a “case” so that we may avoid letting emotion crowd our better medical judgement. Inevitably, we come in contact with suffering and are faced with a choice. Humans without a pathological medical condition can’t meet the face of suffering and feel nothing so the choice is to either engage and take on suffering along with the patient, or disengage as a self-protective mechanism leaving the patient to suffer alone. Since the inception of our training we are taught to be professional and this means not becoming emotionally involved, the tendency is to disengage and leave the patient suffering alone.
There is no point in engaging a suffering patient unless you are suffering with them for a reason, suffering with joy. This can’t be accomplished with the goal of social justice or to fulfill a business plan. Justice depends on giving everyone his or her rightful due. This practiced in excess, especially in certain patients, can have disastrous consequences. In order to practice street medicine correctly, we must rise above justice to give everyone MORE than he is rightfully due. This is done through charity, or love.
Approaching street medicine through the lens of charity is essential because patients experiencing homelessness suffer a lot. This suffering is not just from material poverty which we can cure for a moment by offering food. They also suffer from emotional and spiritual poverty from being discarded by society; of feeling unwanted and unloved. If we are going out to cure, which as medical providers we must, then we also must engage with them in their suffering. This means not just giving medicine to relieve bodily suffering, but to cure means relieving the spiritual and emotional suffering they also carry. To accomplish this, street medicine must be approached through charity and love, not justice.
How or why has this approach to patients experiencing homelessness caught on as a global movement? Street Medicine has caught on because it’s been spread through the joy of suffering and giving through charity. This has turned the light on in traditional healthcare institutions and practitioners. When you turn a light on in a room it doesn’t just shine on the ones you love best, not just our patients, but shines on all in the room, like our colleagues and friends in the community.
Street medicine, at its core, is the light that it gives us permission to share the sufferings of our patients with joy, through charity, with the purpose of healing spiritual, emotional and bodily suffering.

~ Brett Feldman

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.

Image result for maslow's hierarchy of needs

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.

Portland, Oregon is a fascinating city situated on the eastern bank of the Willamette River under the watchful eye of Mount Hood.  As with any city that enjoys a river running through it, the bridges that accompany the river become part of the recognizable landscape that defines its character.  Every thursday night, an army of 150 volunteers turn the space under the Burnside Bridge into a hub of activity and services for Portland’s homeless.  I first learned about NightStrike more than 6 months ago as I was interviewing a prospective PA student who was at DeSales for an interview into our 2016 incoming class.  In high school, she had spent time volunteering under the Burnside Bridge with NightStrike and had sited it as a transformational experience that allowed her to see her own city in a different and profound way.  Brett and I were accepted as speakers at the 2016 National Health Care for the Homeless Conference and Policy Symposium in Portland, Oregon and I decided that NightStrike was something I needed to see for myself.

NightStrike is a program run by Bridgetown Inc and was founded by Executive Director Marshall Snider and his wife Lesley Snider (Program Director) 13 years ago. The organization has 5 employees (including Marshall and Lesley) and in addition to NIghtStrike, have developed several programs targeting the marginalized adults and children in the Portland area. NightStrike alone mobilized over 9600 volunteers serving over 20,000 people experiencing homelessness each year. We arrived at a rented church space near the Burnside Bridge around 630pm and immediately upon entering the orientation space, Marshall and Emily (Development Director) welcomed us to the Program. Orienting over 100 volunteers each Thursday is no small task.  I was impressed by the clear and concise message delivered by Marshall to all the volunteers. The purpose of NightStrike is “Because People Matter” and the common denominator that all humans need and desereve love. He pointed out that the volunteer needs the giving experience just as much as the person needs the blanket and encouraged each volunteer to learn the names and stories of the guests being served. To take on an “Oh there you are!”attitude instead of a “Look here I am” attitude. As an organizer of many volunteers, I particularly appreciated this piece because the message of your organization can be inadvertently misrepresented by the volunteers that are so eager to serve. Another staff member performed the reading of the rules (no photography, let religion come up naturally(if at all), show respect) and safety protocols (walk away from anything that makes you feel uncomfortable, three whistle blows means evacuate calmly and immediately etc).  We then broke into smaller orientation groups for our respective jobs. I was assigned to be a hostess while Brett, Laura, Seth and two friends from Ft. Worth were assigned to the clothing cart. After getting the run down, we all walked down to the bridge where, on average, 350 guests await. The path to the bridge cuts through a green spaces with bubble fountains along the river before arriving at the concrete slabs where we would set up shop.  Rows of Home Deopt style 6 ft tables were set up with folding chairs were already occupied by weary men and women. A mobile dental clinic and a separate mobile medical van created part of the perimeter of our space. The Willamette River and four  occupied barber chairs rounded out the perimeter. A food table with hot chili, drinks and coffee was the first stop for most guests. Other services available that night was a clothing table, library table (with new and used books for exchange), pet food table, a sewing table with two sewing machines to repair clothing, sleeping bags, tents and tarps. I even saw one woman repairing a hot dog costume for a dachshund pup that accompanied his owner everywhere.  There was a bike repair stand with everything from air pumps to tire tubes and chains.  5 volunteers carefully washed the feet of travelers while two more gave manicures to the women. A resource table and veterans table provided critical support for people trying to find their way.

My job was to chit chat with guests. I was strangely appreciative of the fact that I was not the health care provider for the night. I walked around with a thermos full of coffee and poured fresh cups for those waiting in line. I struck up a conversation with a larger than life character named George. A 6’3 black man with a large white beard and a fisherman’s hat. He had fashioned a handmade wooden cart to the back of his bicycle that was packed with elaborate handmade birdhouses.  He told me many tales that evening and emphisized the important points by leaning in, raising his eyebrows and pausing dramatically before letting out the most infectious laugh. During our conversation, many ofther guests stopped by to check out the birdhouses. While George didn’t speak to them, it was clear that he took pride in their interest.

Not all guests were like George. As one would imagine, the homeless are as diverse as we are. Some clean, some not. Some with clear responses to hallcuinations, some not. Some sat quietly, some didn’t. Some preached, some didn’t. But one woman struck me. At first glance, she looked slightly out of place with a fairly new looking hot pink fleece jacket, hair styled, and make up applied. I struck up a converstaion with her and on closer look noticed the all to familiar desperate sadeness in her eyes that comes with not really knowing how you ended up here. She did not reveal any of her story to me other than to say that you do what you have to do to survive.  With that, I poured her a cup of coffee and talked to her about the different resources in the city.

Poverty and how a city assists those who are trying to crawl out from a dark place is a fascinating, and often untold tale, of that which makes up the character of a city. Organizations like NightStrike quietly do the necessary not only to empower the guests, but to remind the volunteers that caring about the homeless population is not futile. In fact, a powerful thing happens when people are guided into being part of the solution.  Well done NightStrike. Well done.

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

When I was younger, I remember driving in the car across the country with my parents. I spent most of my childhood living in Kansas and Indiana but spending major holidays outside of Pittsburgh. This meant many long car rides and my mental curiosity (and predilection for asking endless questions) meant a constant stream of conciousness in the car (God bless my parents). I remember traveling down some road just off the interstate looking for a place to eat and passing a sting of ‘hotels’. I asked my parents if we were sleeping at each one- one after the other and of course the answer was no. In hindsight, they looked like aweful places to sleep with there run down fascade, their “No Vacancy” light that is missing the N, V, C and Y, their broken down cars in the parking lot and a predilection for worn out lawn chairs adorning each side of the door. How welcoming. My mother called these a ‘No-Tell Motel’ and it was only after I got older that I knew what she meant.

Most of us probrably think the same thing when we pass by these establishments that offer a cheap weekly rate, bring your pets, bring your cigarettes and whoever else you want since the front desk clerk seems to only be half in this universe and half somewhere else. An inherant bias that nothing good is happening behind those closed doors and the people who reside there are either up to no good or don’t have anywhere else to be. And afterall, idelness never leads to anything good. To be fair, I have stayed in some of these establishments in my travels and can report that nothing ill befell me, but the sour taste still remains even after plenty evidence of the contrary. Old habits, as they say, die hard.

Below is a story from Brett about how wrong we may be about the goings-on in the local No-Tell Motel. It has been edited with his permission and all relevent names have been changed.

Tom * is a 70 guy who wound up on the street medicine service after i discovered he was homeless during his nursinghome stay a few weeks ago. He worked as a truck driver his entire life until 2008 when he retired. He initially had an apartment after he retired but developed gangrene in his right leg requiring an amputation and a necrotic left heel ulcer requiring multiple surgeries. Almost all of his medical issues are related to his uncontrolled diabetes. He’s been in and out of Lehigh Valley Hospital and St. Luke’s for almost a year and was unable to keep his apartment as a result of his frequent hospitalizations. (kind of challenges that whole notion that the homeless are just alcoholics who eventually had to pay the piper huh?) He does get about $900/ month in social security, but the lowest cost apartments are $700/ month and his meds cost over $200/ month. With no support system, no family, and only 1 friend in a similar situation as his own, he became homeless.

After a recent hospitalization, he was discharged a few weeks ago from a local short term rehab facility to a “no-tell” motel. I pass this motel often and think about how horrible it looks, and the bed bug infestation that must be occurring as I drive by. My suspicions were confirmed by reviews of Trip Advisor and I wonder how anyone would let a human they cared for stay there. Not only is Tim 70 years old with severely uncontrolled DM but he also has a severe tremor making it impossible to check his own sugars. The rehab facility discharged him to the motel with all of his meds, but no supplies to monitor his sugars even if he had the ability. He also had no hime care services set up- no visiting nurse, no meals on wheels.

I visited him the day after discharge and brought him diabetic supplies and supplies to care for his leg wound. I was appalled at the condition in which he was living. He had no access to food and was living off pizza from the shop next door. His fluids consisted on soda from the machine outside his room. The bottle then became a urinal and he had multiple bottles of urine stacked up by his bed. He assured me he would be ok, which of course I didn’t believe, so I returned the next day. Upon my return I found him and his room covered in vomit and he looked like he was going to die. I checked his blood sugar and the meter read, “HI,” meaning his blood sugar was greater than 600. He adamantly refused to go to the hospital because he, “had it with those people and would rather die.” I cleaned him up and brought him some food, but despite my pleading, he stayed.

I called Area Agency on Aging, the VNA, and the Conference of Churches, anyone I could think of who might be able to help me. Two days later I returned to find him looking MUCH better. It turned out that over the past two days the motel clerk and another motel resident had been helping to feed and bathe him. They dressed his wound with the supplies I left, administered his meds to him, and cared for him like a family member. A few other motel residents who were diabetic were coming to check on him regularly.

I thought about community building that occurs when one is all alone, similar to the communities I find in the encampments. If I give a sandwich to someone who is hungry, they will always share with their friends. I don’t know if the same type support and love shown for my patient would have happened at the $200 a night hotel down the street. I realized my own unconscious bias for this motel and will never look at it the same again and I give credit to the fellow inhabitants of the no-tell motel who supported this man when our system let him down.

I stand corrected.