Posts Tagged ‘physician assistant’

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.

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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

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.

Brett and I had an opportunity to give some education about healthcare for the homeless/street medicine to third year University of South Florida medical students. It was a great chance to talk about the unique qualities our patients on the street possess and how they survive. We were incredibly fortunate to have Tyler Rogers, executive director of Safe Harbor (Easton,PA) speak as well. His passion for helping people end their hopelessness is palpable and contagious. The repeating theme in all of our discussion was the concept that everyone matters. Here is a story of a person Brett met today during street rounds with Tyler. It is a testament to why we do what we do and the courage our patients have that we often don’t appreciate.

” I’m incredibly blessed to have the opportunity for service that my job affords. Today was one of those days that reminds me even more than usual the importance of joyful work. I was doing street rounds today in Easton and one of the homeless people we met tipped us off to a young girl sleeping on the street who just arrived from New Jersey. I found her and it was quickly apparent she was pregnant– 28 weeks pregnant– and fleeing domestic violence from her mother who is a crack addict. Her mother has abused her and her brother since they were kids and she always stayed to try to protect her little brother who is now 17 and an addict himself. She felt the time was right to get out of the situation since she feared for the life of her baby because of the abuse. She came to Easton because someone told her she would find help there. I found her and her boyfriend in an alley and told her why we were there and about street medicine. I wish you could’ve seen the look on her face. She has been in Easton for 6 weeks and didn’t know who to call to try to get help or prenatal care. She didn’t have insurance or money to pay so the plan was to go to the ED when she went into labor so she wouldn’t be turned away.

While I was with her we scheduled an appointment for her in the Center for Women’s Medicine. I spoke with the team there myself and she was treated with respect and dignity every step of the way. Now she is very much looking forward to her first appointment next week. Jen, the Case Manager at Safe Harbor, has started the paperwork for her insurance and her boyfriend has enrolled in their job training program. She and her boyfriend were placed in a home affiliated with Safe Harbor today so they can stay together and won’t have to sleep in the streets.”

Sometimes people ask us how we stay encourage. How do we stop from burning out or getting discourage. The answer is simple – Everyone Matters.

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

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.

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.

 

I have been working weekly at several nursing homes in our area for the last few years. I could spend an entire posting talking about how I think our elderly nursing home population ought to fall in the ‘underserved’ category but I will spare you that soap box for today.   I am extremely grateful to have bosses who understand my predilection for the homeless population and for leaving no stone unturned when I’m interviewing patients. It never ceases to amaze me that was the right series of questions you can uncover a world of hurt that the patients been through. When we close our eyes and picture a typical nursing home patient we are stuck with an image of grandma- with her tight rows of freshly curled hair resulting in the beloved (and highly flammable) grandma-helmet-hair. Or maybe a shuffling old man proudly sporting his WWII VFW hat with pins from his uniform.

You are far less likely picturing someone whose reflection resembles yours.

Many of my younger patients have lived in our nursing home system for quite a long time for one reason and one reason only. No one realized they were homeless at any point during the hospital stay or early on in the nursing home stay. Once they started to complete the rehab goals, the social services team comes to the realization that there is no discharge plan. I sometimes referred to this phenomena is the “fog of war- medicine style”.   After 9/11, George W. Bush made many decisions that he later reflected upon in his book “Decision Points”. He realized that perhaps they were not ultimately the best decisions, however, he felt he had done the best he could with the information available and the time allotted to make the decision. He cited the fog of war it during the decision-making process. This is common throughout history and no one really (successfully) faults people for it.

This phenomena also happens in medicine.

It goes like this: Patients are banged up, super sick or maybe have had a decompensation an otherwise chronic stable medical condition which leads to the hospitalization. In the world of hospital medicine, length of stay in the hospital is looked at very closely. In the haste of making a reasonable discharge plan there’s often a lot of questions that frankly just aren’t asked for a variety of reasons. Case managers and medical teams have a difficult job and are often asked to do the impossible. But sometimes, I think we don’t dig deeper into the answers our patients give us about their living situation. For example, patients often say they are going to live with their friend after discharge. At face value, this sounds great. Discharge plan complete. Until you ask if they have talked to their friend about this plan. Often, the answer is no. Or, another common scenario- a patient says they were living with a brother, sister, friend etc. prior to coming to the hospital. Somehow, this is translated by the discharge team that the patient will be discharged back to their prior living situation. No one asks, and the patient doesn’t mention that they can’t or don’t know if they can return. The patient is discharged from the acute care setting (hospital) to their short-term rehab facility and everything seems great until a simple question like “Hey, where you going next?” is asked. The response – a blank look from the patient and then silence sets in.

In the time that Brett and I have been in the nursing home system, we’ve noticed a large variety of patients whose social situations and living situations perhaps were tenuous at best prior to hospitalization. Homeless or not, many people’s social support is based on superficial interaction. Hanging out, watching TV, playing card, shooting the bull (not to be confused with cow-tipping. I am from Indiana after all). In the face of acute illness, that social ‘support’ is tested and often disappears when these patients need the most. The couch is suddenly unavailable. The car has been repossessed because of missed payments. The housing has dried up. Perhaps your truck driver who is now an insulin-dependent diabetic or perhaps had seizures and is no longer allowed to drive the truck. Not only does this person suffer from a loss of employment but many truckers sleep in the cab of their truck. They don’t have permanent housing because they live a life on the road.

A few weeks ago, Brett and I asked case managers from three different nursing homes in three different parts of the Lehigh Valley how many patients they thought were homeless in their facility. Without consulting a census or really doing anything scientific, they came up with 22. That’s 22 patients who have absolutely no where to go if they were to be discharged right now. This is astonishing. What complicates the situation further is that case managers who work in skilled rehab facilities don’t have the training to find housing for patients who are homeless. This isn’t a typical part of any case management training and is purely learned on the job or because of personal interest. And therefore the patients who are easier to move out of the nursing home seem to move out of the nursing home. The homeless patients tend to sit … hang out… and stay. There’s nowhere for them to go and no resources by which to move them.

The Point In Time (PIT) is a physical head count of the homeless on one given night that is universally chosen. Over 3000 cities participate in performing the PIT on this date in an effort to count the homeless and attempt to extrapolate trends about homelessness in your area and nationally. The data is reported to the U.S. Department of Housing and Urban Development (HUD). While HUD says it “does not directly determine the level of a community’s grant funding” (hud.gov), it is required information to report when applying for HUD funding. It would be hard to imagine that those numbers are not somehow taken into account when determining distribution of funding. It is not a perfect sampling tool by any means (a different soap box for a different posting) but it is concerning that these ‘nursing home patients’ are unaccounted for. These are patients that if they were not in a nursing home would be in one of our shelters, on the street or perhaps (if lucky) squeezing out another couch to sleep on. In essence, they should be recognized and counted.

In the last post, I talked about recognition of existence in the context of being a fledgling street medicine program. This same concept applies here too. In order to properly allocate care to the homeless, we must first know where they are. To know where they are, you have to know where to look. The homeless are all around us, hidden in plain sight, waiting to be recognized.