When the homeless can't help themselves

I don't think there's a single doctor in the US who has not had to care for the homeless population. A lot of them have multiple medical comorbidities and can't afford to take care of themselves properly on the street, or else spent whatever money they earn on drugs and alcohol. A lot of these people are regulars in our hospital. There's a 23 year old meth user with ESRD (due to malignant HTN) who never goes to dialysis and instead shows up at the hospital whenever his scrotum swells up (I wish I were joking about this chief complaint) or pruritis. He's so noncompliant that many nephrologists in the city want nothing to do with him; the ED docs don't even admit him every time he shows up anymore. Usually they check his labs and only admit him if his lytes require him to get dialyzed. Then there's a 21 year old type I diabetic who can't afford insulin (another meth user) and comes to the hospital at least once a month (on average) for DKA. When I was a new attending, I felt sorry for him and donated $5 so he could afford his insulin at Walmart. It didn't solve anything; he returned to the hospital the following month. I felt like a fool afterwards; he probably spent that money on meth.

Most recently I took care of a homeless guy with cellulitis who required an I&D of his foot. He was supposed to have gone home the day before, but had refused b/c he was homeless and was not able to receive wound care at the homeless shelter. More importantly (and irritatingly, to me), he said that if he was discharged from the hospital, then he was going to go straight to the nearby county hospital because in his own words, he did not feel safe walking and was afraid he would fall and hurt himself. Never mind that I saw him walking pretty well in his room and pulling his IV pole beside him to boot. I usually feel sorry for the homeless patients I care for, but he definitely wasn't even trying to make me sympathize with him. He was Spanish speaking only so I had the tech in the room to help me translate, and not once did he look directly at me; in addition, I didn't need to understand Spanish to know that he was being a total jerk. I asked if he could stay with his son, and he said no, b/c his ex-wife lives with his son. What was I supposed to do? Discharge him and have him run "crying" to the county hospital that foot hurts when he doesn't even need to be in a hospital anymore? That would certainly look bad for me and my hospital. I went and talked to our social worker about the situation, and she said that since he had Medicare/Medicaid, she'd try to get him into a SNF. "Do you think he'll agree to it?" she asked. Of course he would, if it meant he'd get fed three times a day and wouldn't be stuck outside in 100 degree weather.

Not surprisingly, the patient agreed to a SNF, and further requested (or demanded, who knows) that he go to a SNF where the staff spoke Spanish. If not for the fact that our hospital is big on patient satisfaction (they call patients 2-3 days after discharge for feedback on their stay), I don't see why he should be allowed to choose which SNF to go to. Fortunately there was such a SNF and he was discharged later that same day, but seriously...it doesn't take too much nowadays to become disillusioned with healthcare today.

The night from hell

I've been working nights for the past 4 days, and during my 2nd night, the ED was full of drunks and psych patients. One ED doc grumbled that he was tired of people calling him a "f***head;" a lot of people joked that maybe the supermoon was the reason why the ED was so full. Fortunately for me, drunks and psych patients don't need to be admitted unless they're medically unstable, so I only did 5 admissions that night. Even still, I had the feeling that I would pay for it much later.

Last night was my worst night call to date. I got 4 patients in the first 30 minutes, already a bad start, but I was able to triage them and see them in order of sickest to least sick. However, the admits kept coming, and after 3 hours I had 9 admits and was still at least four in the hole. The ED doc even asked to make sure I didn't have any sharp/hard objects in my hand before he gave me another admission. I was hoping there would be a time where I'd be able to catch up on my admissions and not be 2+ in the hole, but it never happened. I was in the hole all night, and as the admits kept coming, I'm sorry to say that I also became angrier and angrier. Usually I'm good at keeping my emotions at bay, but not last night. I was slamming charts on the table, dropping f-bombs when talking to the ED docs as they gave me yet another admission, and slightly rude to the floor RNs who called to say their patient needed a sleeping pill. By the end of my shift, they'd given me 16 admissions, of which I could only complete 15 because I didn't have time to see the 16th. I didn't finish dictating my h&p's until nearly 7 a.m., a whole hour after my shift ended. If I'd seen that 16th patient, who knew when I would have left the hospital. At any rate I was in a completely bitchy mood as I left the hospital, which I'm sure did not go unnoticed by my coworkers.

Went home, slept for 4-5 hours, then treated myself to a 60 minute massage (found a 20% off coupon in my inbox, decided to use it). There were a lot of knots in my lower back and neck (no surprises there; I've been waking up stiff for the past few days), but those got smoothed out by the therapist. It was just what I needed after 4 days of working nights; I feel better now =)

Prisoners

I recently had a patient get admitted for a-fib, and I learned that he'd been in a correctional facility (aka prison) for the past five years. I don't know what he did to earn such a sentence (and who knows how many years he has left), but he was one of the nicest patients I'd ever had the pleasure of caring for. A few nurses and I wondered what crime he had committed in the past that landed him in prison, and in a way, I don't want to know. I'd rather keep the memory of him telling me, "God bless you" when I told him he could go home, rather than learning that he did something heinous like assault another person or commit murder. That reminded me of another patient I admitted one night, and the "what-if's" still haunt me once in a while.

Last month when I was working nights, I admitted a 29-year old male with asthma exacerbation. He said that he had become short of breath while walking on the street; I remembered he was pleasant to talk to. The following night  I heard a "Code Purple" (code for "Aggressive patient or family member") overhead pointing to his room, and I wondered what could possibly be going on because I remembered him being a nice guy and unlikely to cause trouble. Usually I stay away from Code Purples; security usually deals with all that, and I didn't think much of it later. I found out later that he had gotten into an argument with his ex-wife who had come to visit him.

Later on, I looked the patient up to see how he fared after he was admitted. Then I got a huge surprise: the patient's mother had called the hospital saying that he had told her that he had knives in his room and that he was going to hurt himself and some of the nurses who kept coming into his room and "bothering" him. In fact, he had used a fake ID to get into the hospital; in reality, he was wanted by the police for assault (apparently tried to choke his ex-wife prior to coming to the hospital) and has a strong history of violence. He'd had a bag in the room with him that he'd refused to let the nurses handle; when security searched him at the social worker's insistence, they found a machete and another knife in the bag. He then began making threats and ranting that there was a hitman out to get him. The police was then called to take him to jail.

I was speaking to one of the nurses about this today, and she commented that she and another nurse had "been chatting with him" most of that day, and no one knew that he had a knife in his bag. What if he'd chosen to act on his paranoia? What if he pulled out that machete in the ER while my back was turned and sliced off my head? What if he stabbed the nurses instead and then proceeded to attack other people in the hospital? I imagine something like that would have made national news and brought up the issue of safety in hospitals. How the hell did the patient get a MACHETE into the hospital? I know we don't have metal detectors, but usually personal belongings are well documented prior to the patient leaving the ER. I hate to think about what could have happened if the patient's mother didn't call the hospital, what kind of terror he could have unleashed if he became any more unstable in the mind. We were very lucky.