Posts Tagged ‘physician assistant student’

The Street Medicine Institute and I share a vision where all neighbors sleeping on the streets around the world will have access to healthcare in a location and manner acceptable to them. Over the last decade I’ve witnessed this vision inch closer in cities all around the world and I’ve had the honor to serve the most genuine and loving people you could imagine. I’ve witnesses the evolution of reality based medicine in the Lehigh Valley from in front of my backpack.  When the DeSales Free Clinic opened in 2007 it was the only healthcare being provided directly to the homeless in the area but now there are 10 clinics, a sprawling street presence, a medical respite and the ability to enter any hospital in search of our people. The communities as a whole has galvanized support and started a winter shelter in Allentown, Bethlehem and Easton, where before there were none. If a new person is seen panhandling off any freeway within hours we are called with hopes we can provide some help to the person. Most often, the call comes from someone outside of the healthcare field who just wanted to do something to help. There is still much work to do but the community is strong and our team at LVHN is getting stronger every day supported by senior leadership that not only understands the mission, but has allowed our belief that everybody matters to infiltrate ALL patient care to the benefit of so many.

In December 2016 I was asked by Dr. Kevin Lohenry, the Director of the University of Southern California (USC) PA Program, to deliver the Keynote address for their White Coat Ceremony and for the first time in my adult life I witnessed the intense poverty and immense number of people sleeping rough on the streets of Los Angeles.  The streets look like a post-apocalyptic wasteland of humanity. As I stepped over the bodies using the streets as their living room, bedroom and outhouse on the same corner, I felt utterly useless to help them and needed to learn more. Over the subsequent months, Corinne and I met with the dedicated servants of the homeless in LA working for various agencies and FQHCs all sharing a common goal. Although the number of homeless has risen over 20% from the year prior, there was a palpable sense of renewal and drive to push harder. The citizens of LA felt the same way and voted to increase their own taxes with funds going to help the homeless. With the belief that, “an excellent private research university should take on the most intractable, multifaceted problems of our time,” the USC Provost, Michael Quick, announced that USC will play a large role in the effort to solve homelessness in LA. It seemed that the large number of rough sleepers in LA was only outpaced by unwavering desire to help them.

It is on this back drop that Corinne and I have made the decision to join the many incredible and talented servants trying so hard to help our neighbors experiencing homelessness in LA. In April, I will begin as the new Director of Street Medicine at USC.  Corinne will serve as faculty in the USC PA Program and will have time set aside for working with me on the street team and pursuing much needed research on the rough sleeping population. It’s our hope to contribute in our simple way to the complex work needed on the streets of LA. It’s our aim to further an understanding of our friends sleeping rough through research so that we may all better meet not just their needs, but help them renew their dreams as well. If we are to fulfill the vision that all people sleeping on our streets will have access to healthcare then there will need to be many more street medicine programs and providers throughout the world. There is no better training ground than LA, and no University more poised to dissect this issue. With this in mind, we will be working on the creation a pipeline of well-trained providers in the art and clinical acumen needed to practice street medicine properly will be created.

My time at LVHN serving the homeless in the community along-side so many special people has been the honor of a lifetime. I leave behind a team that I have no doubt will take great care of our patients and continue the work much better than I could ever have done.

We begin our work in LA with the blessing of obedience to HIS work. Not on a new mission, but a continuation of the same. He has given us the inspiration and grace to begin. As our mission moves forward, you will be able to follow our journey at streetmedicinela.org. Corinne and I humbly ask for your prayers as we continue our journey of walking with the homeless

Sincerely Yours,

Brett

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Sitting on a tarmac outside of the Newark NJ airport, I am trying to wait patiently for my plane to take off. I hear mostly white noise as people are shuffling to their seats and stuffing oversized bags into small overhead compartments. I look to my right and see a recent DeSales PA Program graduate sitting a few seats away. In the midst of our boarding process, I hear words being shared about street medicine and homelessness to the unsuspecting middle seat passenger. In 6 hours, Seth could have her convinced to attend the 11th Annual International Street Medicine Conference with us.

 

While I don’t often spend much time reflecting back on progress over time, I find that preparing for conferences like these tends to send me back to a time when I knew less in both knowledge and people. Two years ago, Brett and I attended our first International Street Medicine Symposium in Boston. We had read so much about the world-renowned Boston Health Care for the Homeless Program (BHCHP) founded and flourished by Dr. Jim O’Connell. I had followed their website for years and had a visit to BHCHP on my bucket list for years. (Hey, some people sky dive, I visit homeless programs.) The opportunity presented itself for this visit with just a few weeks notice. Generous support from both of our sponsoring institutions (to let us go) and family (to keep our kids) allowed Brett and I to travel that Fall to Boston. It was the first time we were able to see a mature and robust healthcare for the homeless program and see first hand how something like that is grown and cultivated over time. Each member of BHCHP seemed to share the vision that had begun more than 20 years before. They were motivated, enthusiastic and committed. At a dinner reception after the first day, Brett and I met Dr. Jim O’Connell for the first time. He was genuinely interested in our small but eager programs. I mentioned that the DeSales Free Clinic has an operational budget of about $18,000. I’ll never forget his response. “You do all of that with $18,000? I have a multimillion dollar budget. It sounds like I have something to learn for you.” I was dumbfounded. You? Learn something from me? It sounded laughable ( and still does) but he was sincere. And a reflection of how all Street Medicine Programs are treated by their peers. This type of interaction has been repeated many times over as street medicine programs come from all over the world, once a year, to learn, share, eat, drink and be merry. Dr. Jim Withers of Operation Safety Net (Pittsburgh, PA) once told me that he thinks that people at this conference and his patients sometimes understand him better than his family. (True)

Now, we are heading to San Jose (CA) for this years conference. Our programs have grown exponentially since that first trip to Boston. So many ideas were illuminated, so many seeds planted. We are travelling with 8 other street medicine team members- 2 University of South Florida SELECT medical students, 2 DeSales University physician assistant students, 2 recent graduates of the DeSales PA Program, LVHN Street Medicine’s new case manager and new clinical coordinator. It is hard to imagine the life trajectories that can change when armed with the knowledge that comes from conferences like these. Brett and I sometimes joke that it feels like you are going away to camp. The time is short, the bond is strong.

Caterpillars are not particularly ferocious creatures. Slow and steady and according to my children, very hungry. I am not even sure that they make any noise at all. Or, come to think of it, have any teeth. They do their thing in their unassuming way and eventually make it to butterfly utopia. Silently and without bells or whistles, they make the world a more beautiful place. I have often marveled at the way passion can turn an otherwise quiet and unassuming human into a bull in a china closet. I am certain you have witnessed this phenomenon and it can happen to any of us. Once, while sitting in an ethics lecture some years back, a girl who I had never heard even speak suddenly found her voice and schooled the room about the seemingly double standard in the world regarding when life begins. Looking around, her point had not only been made, but her peers were blown away by the passion that was residing within her.

Advocates for many causes are much like the girl I just described. I remember a neighbor I had who loved animals. She always had a foster animal that she was rehabilitating for adoption. She would spend hours nursing the animal back to health. Once, I got up to go to the bathroom late at night only to glance out the window and see her sitting beneath a porch light picking fleas out of a sad lump of fur. I didn’t understand it then, but I do now. For some people, it is animals or organic food. The environment or breast cancer or autism or homelessness. World hunger, toxic waste or children in Africa. The cause is different but the root is the same. All causes need passion like this. It is what inspires other people to give two rats patooties about something they otherwise couldn’t care less about. I often think that I relate more to people who are passionate about SOMETHING (even if I fall into the rats patootie category about the cause) than those who are indifferent about EVERYTHING.

I am often asked how we do it all. I can see the look in people’s eyes as they ask the question. It is a third happy, a third bewildered and a third concerned. They know we have many clinics and homeless responsibilities. I myself work one full time job and two per diem jobs in addition to my obligations to the homeless. We have three children and other community responsibilities. I know why they are worried and why I am not. The answer is simple. I am compelled. I know that it is not I who is in charge of this master plan. Tenui nec dimmitam- latin for “I have taken hold and I will never let go.” This phrase reminds me to breathe easy, let it go (not the Frozen kind) and have courage.

Caterpillar roar.

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.

As I do every Friday, I was rounding at one of our local nursing homes after precepting the night before at the DeSales Free Clinic. Friday mornings like these are always particularly challenging for me as I am often struck not by the differences but by the similarities between the ‘underserved’ unsheltered/sheltered homeless and the ‘underserved’ elderly living out their days in a nursing home. Nursing homes are not all doom and gloom and depressed mental pictures of our loved ones wilting away just as caring for the homeless is not a fruitless effort bound for failure. There is actually a great deal of love taking place in both settings. Don’t believe me? On Friday, a long time patient in the nursing home suddenly took a turn for the worse. I frantically wrote orders for medications that I though would ease her transition out of this world. One hour and fifteen minutes later, my lovely patient left this world to another. She left so quickly that her family was not able to make it to her bedside in time. Instead, she was loved out of this world by a nurses aide and an activites assistant to the hymns of her childhood and recitations of her favorite passages from the Good Book. So often, we in medicine think that our only measure of success is cure. I solomnly object.

Last year, I saw a patient in the Free Clinic with one of my students. The student had done a great job seeing the patient, coming up with a reasonable plan and conveying it to me. The patient essentially had a terrible cold. No need for antibiotics or anything more than some OTC medications that we could provide. From my seat in the presentation area, I could see the patient out of the corner of my eye. He looked terrible. Not the “call an ambulance” terrible, but a weary-feverish-please-just-let-me-rest terrible. As we went into see the patient together, we realized he was in the emergency shelter which clears out no later than 8am. This man would wander the streets and try to find somewhere to rest until the shleter opened back up. Your daily goal of survival is rarely replaced with rest and recooperate. It turned out, this man had a car (eureka!). He also had a brother 1 hour north who was going to be away for the next week and had offered my patient the couch while he was away. The problem? The patient’s car needed antifreeze and he had no money.

As we returned to the waiting room, I asked my student to share a memory about being sick and the things that helped him feel better. Then i asked him to remeber how sick he felt and picture not eating or drinking and then walking around or sitting in 20 degree weather while the wind slaps your face as if to remind you of your worthlessness. Before we learned the patients social situation, we of course knew that we couldnt cure his cold. Most viruses are just a test of our patience since more of the things we give for comfort only work marginally well at best. But we were nonetheless ready to arm him with Mucinex, Robitussin, Motrin and anything else we thought would help. In reality, what he needed more, was rest. And the best way to get him rest, was to get him antifreeze. On the way home from clinic that night, I bought him two large containers of antifreeze and dropped them back off the next morning where a very greatful patient awaited and at last would get a good nights sleep.

In street medicine, as with the nursing homes, we cannot simply cure the root cause that landed our patients in ther current surroundings. It is the complex fabric of their lives and health that have to be carefully understood before real comfort -and perhaps cure – can be achieved. This can be a real challenge to newcomers to these areas of medicine. There is a potential for new providers to become frustrated and overwhelmed and run for the hills while wildly flapping their arms screaming about the unfairness of it all. What we find in street medicine is that often the cure comes from the comfort. The brokenness cannot be cured with pills. It can only be cured with comfort. Comfort doesnt’t take money, doesn’t take insurance (thank God) and doesn’t take a master’s degree. It actually takes something much more valuable. It takes tenacity mixed with vulnerability to go there with your patient. To a place that is raw and uncomfortable and can chalkenge you in ways you never thought possible. To a place where we celebrate the small victories and push on when set backs occur. In many ways, this is what our patients need more than anything else. Belief that they are actually worthy of something better than this.

“Sometimes it’s easy to walk by because we know we can’t change someone’s whole life in a single afternoon. But what we fail to realize is that simple kindness can go a long way toward encouraging someone who is stuck in a desolate place.” – Mike Yankoski

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