Posts Tagged ‘Medical student’

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.

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

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

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

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

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.

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.

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.

In the Spring of 2013, Brett came across a conference being held in Washington, DC a few weeks later. We scrambled with our employees and our families to find coverage for the many hats we wear and off we went to the National HealthCare for the Homeless Council conference.  I have been to many, many educational conferences in my professional career and I can say that up until that point, none of them would be described as life changing.  Prior to our attendance, we had been running the DeSales Free Clinic since 2007 but had not really met other people who were doing the same things. Two things happened at that conference that changed the trajectory of our lives.

First, we were able to see that what we had created at the DeSales Free Clinic was as comprehensive and well thought out as many of the programs who were presenting their healthcare models at the conference. We always felt in our hearts that what we were offering was logical and right but we really had nothing to compare ourselves to. The second thing was that we were able to meet all of these people that were offering healthcare to their homeless population in ways we had never even thought of.

It was like a mental explosion.

I remember sitting at a restaurant with Brett after the conference was over.  We made a plan at lunch that day about what we wanted homelessness medicine to look like in our area. It was suddenly blinding that what we were doing was great but there was SO MUCH MORE that needed to be done. More people, more locations, more populations, more awareness. For both of us, a sudden and sharp vision (blessing)was born.

We wanted to start with developing a Street Medicine Program. We don’t really know how to do anything small and so considering starting something in a logical-one-step-at-a-time method is a nice theory but we know we’ll blow it right out of the gate. We knew that the biggest job was two fold- 1) convince important decision makers that the Lehigh Valley has a homelessness problem and 2) Get buy in for this never-heard-of-it-before type of medicine called Street Medicine.

A few months after the NHCHC conference, we attended the International Street Medicine Symposium in Boston, MA. Again- mind blown. The benchmark program- Boston Health Care for the Homeless Program- hosted the conference and I thought our heads were going to explode on the car ride home.

Today, Brett starts as a full time Street Medicine PA in the Lehigh Valley Health Network Street Medicine Program. He has worked tirelessly at the hospital and had more meetings in the last year than I think he ever thought possible. It’s funny but Brett is more of a do-er and less of a talk-er but he knew that he had to get people to see the vision as clearly as it lived in our heads. He met with grants people, finance people, security people, mechanics, community partners, HR, PR, IT, development, department chairs, managers…he learned about departments that we never knew even existed. And amazing people who were willing to help in any way that they could to give this idea legs.  Their eyes were opened and all of a sudden, they couldn’t imagine why we hadn’t thought of this sooner. He did lunch meetings, breakfast meetings, stand in the hall and chat meetings. The goal was to create an idea so big that once your ready to ‘go live’, it would be nearly impossible to stop. Their eyes were opened and all of a sudden, they couldn’t imagine why we hadn’t thought of this sooner.

Everyone has a different dream and I feel like very few get to wake up and do what is living in their heart all day. There is a pure joy that escapes unabashedly out of a person when they are doing what they love. Today is that day for Brett.  Dream big or don’t dream at all.

” It ain’t about the money you make, when a record gets sold, It’s about doin’ it for nothin’, ’cause it lives in your soul.”  – Eric Church

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. 

 

 

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

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

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

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

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

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

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

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