I met John a few days ago on a bitter cold morning near the start of my shift in the emergency room at Rhode Island Hospital. John was in his late fifties, with a big, bushy gray-white beard and a twinkle in his eyes. Add a red velvet suit and matching cap and he could have passed for a department store Santa Claus, if it wasn't for the overpowering smell of feces that emanated from the stretcher where he lay in our busy ER. A few feet above his head, an electronic monitor beeped, flashing John's blood pressure of 205/95 in bright red numbers on the small screen. I had to walk over and silence it, so that I could concentrate on the story John was trying to tell me about his life, or at least the past few weeks of it.
It wasn't an easy story to hear, given the difficulty of John's life, nor an easy one to follow, given the wandering nature of his speech. Like so many of the chronically homeless across America, John has significant mental health issues. Luckily, John's son Ted was there with him, seated on a chair next to his father's stretcher, able to fill in some of the gaps and inconsistencies, though he had not actually seen his father for several months. As it turned out, Ted was also homeless but, as he characterized it, far better able to cope with the demands of life on the street than his father. "You got to be savvy," Ted told me, "and my father's just not like that."
Indeed, the numbers seemed to back up Ted's assertion. In addition to John's astronomically high blood pressure, he also had out of control diabetes and high cholesterol. Worst of all for him, John suffered from chronic diarrhea that would occasionally burst out without warning, resulting in his eviction from more than one shelter or facility over the years. According to his medical records, John was supposed to be taking a dozen different medications to manage his many medical conditions, but he couldn't remember the last time he'd taken any of them. "Maybe a few days ago, or maybe last month," was his best guess. He'd actually been in another emergency room across town just the day before, where they had given him prescriptions for refills of all of his medications before discharging him to the street, just as the first major snowstorm of the season was beginning to roll into Providence.
Luckily, John had managed to make it to a shelter before nightfall, though his new prescriptions hadn't made it there with him. "I guess I must have lost them in the snow the first or second time that I fell on the way," he explained. It was at the shelter that night that he happened to bump into his son, whom he hadn't seen in months. Ted couldn't believe that his father had just been sent out from the ER into a snowstorm, his pants still soiled with diarrhea, and so he had brought his father to our hospital to see if there was something more we could do to help him.
In many ways, John's case is illustrative of a large portion of the patients that populate the emergency rooms of hospitals across America. Over the past thirty years, the emergency room has become America's last (and sometimes only) safety net, catching those who fall through all the many cracks in our society. About half the patients we see in our emergency room have at least some social component underlying their visit, and I would estimate that for about a third of those patients the social issue is their primary reason for seeking care, far outweighing any direct medical problem.
For many emergency physicians, including myself, this is one of the very reasons we chose our specialty, the only one in America legally mandated to care for all people regardless of their ability to pay. Early in medical school I had decided that I wanted to practice medicine on the ground floor, surrounded by the full spectrum of human medical, psychological, and social conditions. As Lewis Goldfrank, the chair of emergency medicine at Bellevue Hospital in New York once said to me when I was still an impressionable medical student, the emergency room provides a person with a biopsy of their society. The fewer protections a society affords to its poorest and most vulnerable, the busier the emergency department becomes and the greater the proportion of social ills it contains.
After nearly a decade of this work, though, I have come to realize that there is something incredibly masochistic about choosing to work in a setting where I have a front row seat to all of society's ills and yet none of the proper tools to fix them. I am both well trained and equipped to treat a heart attack, a stroke, a broken leg or a lacerated hand, but other than bear witness, there is little I can do to for homelessness, hunger, domestic violence, gun violence, alcohol/drug addiction, or lack of access to primary medical or mental health care. As I spoke with John, I felt a complex mix of empathy, compassion, and impotence, already knowing, before he even finished telling me his story, how it would end that day.
Which is not to say we did nothing; indeed, we placed several drops in his bucket. We gave John a turkey sandwich and a can of ginger ale, two of the most ubiquitous supplies in any urban emergency room. We gave him his daily doses of the twelve medications he was supposed to be taking, which did bring down his blood pressure, at least temporarily. A medical assistant helped him shower in our chemical decontamination unit, and we replaced his soiled pants with a pair of clean (though not very warm) scrubs. We searched for an acute medical condition that could warrant an admission to the hospital (his chronic medical conditions, as poorly controlled as they were, were not reason enough). When we found none, we consulted psychiatry, to see if his untreated mental illness might warrant an admission to their service. Not unless he's actively suicidal, they said, which, despite all of John's many misfortunes in life, he wasn't. Next we consulted our case manager and social worker, but John didn't meet criteria for nursing home placement and couldn't afford an assisted living facility. Finally, we tracked down a nephew of John's in neighboring Massachusetts to see if he might be able to take in his uncle, at least for the holidays, or help us place him in an assisted living facility. John's nephew, though, wanted nothing to do with him. Merry Christmas indeed.
And so, just as the other ER across town had done the day before, and just as others are likely to do many more times before this winter's end, we discharged John to the street with directions back to the nearest shelter and a neatly printed set of twelve prescriptions that he would never be able to afford (assuming he could even manage to hold on to them long enough to get to a pharmacy).
I spend much of my year working in Africa and South-Asia, and one might think that the scope of the problems I see there would easily dwarf anything I might witness in an American emergency room. Yet, there is a palpable difference between working in a resource-limited setting such as Africa, where nearly everyone is either poor or just getting by, and a resource-stratified setting such as America, where we have more than enough shelter, more than enough food, more than enough fuel, and certainly more than enough health care, and yet there are still large numbers who go without basic needs. Indeed, just before retiring for the Christmas holiday, our Congress adopted a two-year federal budget that cements in place sharp cuts to national food assistance programs and fails to renew benefits for the long-term unemployed (and most still considered it a Christmas miracle that at least some Republicans agreed to vote for this budget without far steeper cuts). It seems that many in Washington remain quite worried about America's long-term budget-deficit. From my front row seat on the ground floor of the hospital, though, I remain far more worried about America's long-term compassion-deficit.
Note: All names in this piece have been changed in accordance with the Health Insurance Portability and Accountability Act of 1996.
Adam Levine is an Assistant Professor of Emergency Medicine and Director of the Global Emergency Medicine Fellowship at Brown University. He currently serves as the Clinical Advisor for Emergency and Trauma Care for Partners In Health/Inshuti Mu Buzima and as a member of the Emergency Response Team for International Medical Corps. His research focuses on improving the delivery of acute care in low-income countries and during humanitarian emergencies. The views expressed in this blog are his alone and do not necessarily represent the views of any of the organizations mentioned above.
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