Streets

Been a cold snap in the area. The Red Cross opened warming shelters in the downtown core, for the homeless population. At breakfast today, after work, one of my coworkers, another nightshifter, railed against the city's policies.

"I don't know what it is, they love the homeless here. I think they're way too nice. That's why we've got such a problem!"

I sat quietly, eating my eggs, and didn't disagree.

* * *

Two nights before, we got called to a shelter on chest pain. An elderly man lay on the ground.

"My arm hurts," he told us, fumbling in a pocket. "S'my angina. Gotta take my nitro."

Someone had told the dispatcher he'd been drinking, so a couple cops showed up and watched as we loaded him on the stretcher.

As we worked him up, in the ambulance, ECG and IV and all the rest, I tossed a few social history questions in with the medical ones. Homeless? Yes, he said, and I winced, looking down at my notes. He was well over 70. Too old to be on the streets, especially with his medical history.

Why was he homeless? Did he drink? Not really. Drugs? Hell no, he told me. Finally he told me he was a few months out of prison. Had been in for the better part of two decades. I nodded. After a few minutes, my curiosity got the better of me.

"Sir, can I ask, what were you in prison for?"

"Eh. Some guy. In a bar. Committed suicide."

"Suicide? And how--"

"Committed suicide on my icepick, he did."

I was glad he said it with a smile; that way I didn't have to hide my own chuckle. Shouldn't be laughing about a crime like that, but I couldn't help myself.

Later, sitting on a streetcorner, I told my partner how bad I felt for the man. Made a mistake, did his time. Polite, friendly, nice as any other patient I deal with. Left out on the streets. Ain't fair.

* * *

I've been doing a lot of thinking, lately, about the homeless and disadvantaged populations that we so disproportionately serve in EMS.

It's easy, so very easy, to get frustrated with people who are abusing the system. To simply see the endless repetition of fradulent complaints, transparently intended to get a warm bed for a few hours, a meal, pain medication, attention. And to be stuck in a system that is vulnerable to such abuse, because they might just have a medical problem, and everyone is entitled to emergency treatment and care.

On the one hand, I believe firmly in personal responsibility, and I think that individuals should attempt to help themselves before they reach out for help. That means sucking it up, dealing with the nausea and vomiting of a viral illness, taking a cab or the bus to the hospital for your foot pain, and basically not using emergency services for primary care. Or for a warm bed and hot meal.

On the other hand, I recognize that a big part of the problem is the system. We're afraid, in this country. Afraid of lawyers. Afraid of giving our medical providers the discretion to triage out people who, 99% of the time, don't have an emergent medical need, for the sake of the 1%, or 0.1%, who present completely atypically. It's a delicate balance, but we're way on the wrong side of it. If I could take half the patients I see, evaluate them with all the tools I have, and refer them to a primary care resource, the overall burden on the EMS/ED system, as well as society, would be greatly reduced.

Likewise with the homeless population. I know that 90% of the people who are homeless have, as a contributing factor, substance abuse or mental illness. I know that these are the people who are hardest to reach and help, even with shelters and programs and social services. I recognize that these are the people who have the deck well and truly stacked against them. I don't really want to be another part of the system that doesn't care and keeps screwing them over.

But I wish, I truly wish, that when I get called down under the bridge at 4am for unconvincing chest pain with no supporting history, 12 lead, or vitals, I could just look them in the eye and say, "Seriously, are you just cold? Be honest. We'll run you over to the shelter. Let's get you a meal."

Because I feel -- on the basis of no evidence, simply my anecdotal experience -- that this is really what a significant portion of our homeless patients want.

Maybe I'm a jaded, cynical asshole. I don't know.

* * *

Last night we ran a call in a suburb for "frostbite." The east wind coming down off the mountains made it bitterly cold, and I turn up my collar and pull down my wool hat as we get the kits out of the ambulance.

The man, in a convenience store, is concerned about his hands. They're fine. He's not, however; he's a transient, out in an unfamiliar part of town, and the more we talk to him the more it becomes apparent he has serious mental health issues. He's high-functioning, relatively speaking, but paranoid, and maybe a bit delusional. But he's alert and oriented, and when we tell him he doesn't have frostbite he refuses transport. He says he's trying to get up to Washington, on the bus. He's thirty miles from the bus station.

My partner pulls me aside. "Is there a warming shelter out here?"

I shrug. "I don't think so. Let me call the comm center, see what they know."

The dispatch supervisor doesn't think there's a shelter out in this area, but says he'll send police by, to see if they can help us facilitate some solution. We wait onscene, talk with the man some more.

When the cop shows up he seems grumpy. Asks why we aren't taking him to the shelter. I explain we can only go to the hospital. Why don't we take him there, then? I bite my tongue, take a breath. He doesn't have a medical problem and doesn't want to go.

"Alright," the cop says, finally getting out of his car. We leave him talking to the man. I'm sure the cop will just check him for warrants and take off. Especially if the only shelters are all the way back in the core.

An hour later I pull up the police call on our computer. A single line of text, down at the bottom, tells me that the officer transported a male all the way into town. To the warming shelter.

Well, then.