Homeless Patient?

[SomniusLumen]

So as a forewarning: this may be me just being sentimental, but I am genuinely curious about this situation.

I spend my weekend mornings volunteering at an ER and I distinctly remember last weekend a certain patient. One of the reasons I do remember him so clearly is because of his disfigured face. I also remember him because when I came in around 7:30 that morning, one of the doctors there was yelling at the patient to wake up so he could talk to him. I thought this was a bit peculiar, but I had dealt with my fair share of uncooperative patients. Then, about an hour later, one of the nurses told the patient to wake up. I didn't catch the entire exchange, but I noticed that the nurse was hitting the patient's arm, as if stirring him awake. When I looked away again to help another nurse, I suddenly heard shouting: the patient was yelling at the nurse and the nurse was replying with expletives such as "get the f*** up!" and stuff like that.

Anyways, the nurse discharged him and told the patient to leave. The patient, however, told the nurse that he had nowhere to go. The nurse didn't seem to care and asked me to escort the patient into the lobby to leave the hospital. Now, looking back, I wish I had talked more to the patient after escorting him. This evening, I was driving home from campus and I was turning on an intersection when I saw a homeless man walking up the sidewalk, begging for change. When he turned around, I noticed that it was the same exact patient! His words suddenly rang in my head and I realized that he really was homeless.

Anecdote aside, I'm just curious: what are such policies for homeless patients? If they tell a hospital that they don't have anywhere else to go, is it really not the hospital's responsibility to find some place for this patient? Especially if we're in a polar vortex? Moreover, was the behavior of the nurse and the doctor completely warranted? I can't help but feel that they may have treated this patient so roughly just because of his disfigured face and his lack of home, but I can't be too sure of course.

What do you guys think?

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[deleted407021]

We have a few homeless patients at our clinic. All we can do is refer them to homeless resources. I imagine the hospital had done that previously, and he was just loitering for want of some place to go. Judging by the behavior of the nurse and doctor, it doesn't seem like that had been his first visit.

 

[MedPhys2MD]

I really empathize with the homeless patients I see. Unfortunately, many of them I've worked with also have mental issues as well. I've been asked for money many times at work.

Regardless of the visit frequency or reason the patient was in the ER, they are still a person and shouldn't be talked to in that manner. That's beyond the fact the RN should not be using profanity audible to others at work. If you heard that, other patients likely heard it as well and that's completely unacceptable.

 

[Mt Kilimanjaro]

So as a forewarning: this may be me just being sentimental, but I am genuinely curious about this situation.
snip
What do you guys think?

Stories like this are difficult for anyone to comment on because nobody knows the full story. Regarding hospital's obligation to the patient, check out the first link.

Here's some related stuff to check out:

http://www.acep.org/content.aspx?id=25936

"Lost Angels" on Netflix.

"The Waiting Room" on Netflix.

 

[Chir0nex]

Context matters here. You have no way of knowing if this has been a recurrent issue with this patient, if the patient had been especially difficult, or any other number of details that could have lead to the altercation you saw. Yes, the nurse could have handled it better, but I have worked at clinics where you get frequent fliers who literally are there every week and never follow-up on any of the help and resources you provide them. It is an incredibly frustratng experience for everyone involved.

Legally speaking I don't think there is an obligation to secure housing for a patient. Often times social services can help find a place for a night or so, especially on cold nights, but in the end there is a limit to the resources the hospital can offer and it is not meant to be a homeless shelter.

 

[Ismet]

I imagine the hospital had done that previously, and he was just loitering for want of some place to go. Judging by the behavior of the nurse and doctor, it doesn't seem like that had been his first visit.

This. I am absolutely not saying that the nurse acted appropriately, as what s/he said was completely unprofessional. However, the times that I have witnessed nurses and doctors being unwelcoming to patients is when the patients are ED "frequent flyers," often seeking drugs or just loitering. As a once-weekly volunteer, you may have never seen this man in the ED before, but this may be the 10th or 20th time this nurse has had to remove the man. While her actions and words were extreme and rather uncalled for, if this is the case, it can be a frustrating situation for the nurse or doctor. They could have referred the man to homeless resources, called social services, etc, but maybe they've tried that several times before to no avail? The ED is not a hotel or a shelter.

 

[SunsFun]

Ideally there should be a social worker handy to take care of this guy. I don't see why this should be a responsibility of a doctor or a nurse to handle discharges at the ER. As it was mentioned earlier, homeless people often are in distress, have other underlying problems such as drug addiction, or even mental issues. I personally would hate to show someone like that the door. Unfortunately our safety net is just a bandage with tons of holes in it. Those people don't just end up in ER all the times because they like it better than a readily available shelter. They overstay their welcome everywhere and ER is often the only place that keeps taking them back.

 

[Ashley1989]

1. The nurse cursing at him is very unprofessional
2. If it's during the polar vortex then keep the poor man inside unless you want to see him early the next morning while treating him for frostbite or hypothermia. Just keep him in the lobby or something.
3. If this continues to bother you then seek out your volunteer coordinator and speak with them. They will probably know the norm for your individual hospital as far as protocol for patients like this. Just don't drop names of the nurses etc that's not cool.
5. I'm a little drunk at the moment so I might disagree with my advice in the morning
Edit: actually more than a little. So let me see what I think in the morning lol
Edit #2: feel really sick now but yes, I still agree with my advice lol

 

[HopefulReapp]

We get a lot of homeless patients in my hospital. I am pretty sure there are two different policies. If they are admitted, the case manager has to find placement for them. This is most likely at a shelter or the psych hospital. If they are not admitted (ER), they are discharged out the front door. The attending suggests a shelter and surrounding clinics, but I don't think they have any obligation.

A lot of the time homeless patients just go to the ER for a warm place to sleep and some free meals. I'd say half are nice and half are not nice in my experience.


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[sakata8242]

Sounds like a frequent customer who just wanted a place to nap. The ER is not a hotel, or social services. The unpleasant reality is that if they discharged him there was nothing acutely wrong with him and he was taking up bedspace and manpower.

 

[Jennyfishy]

When I shadowed in the ER, I met a couple patients who were treated similarly, but not as unprofessionally (the ppl just talked a lot of **** at their work spaces/breakroom etc.)

One of the physicians later told me that they were "frequent flyers" who were homeless and often called 911 and requested transport for arbitrary reasons. From a business perspective, it was a waste of money and resources to tend to the person since there was nothing wrong with them and they were just trying to get meds + a bed for free. Apparently one of the patients came in at least once a week! 😕

 

[Law2Doc]

"homeless" is a politically charged word and probably should be avoided. It generates notions of a person just down on their luck. in fact for most of these people being "homeless" is a sequela of other problems, not their actual problem. Mental issues and substance abuse issues are most often the real culprits, but you generate a lot more compassion from the masses calling someone "homeless" than calling him a schizophrenic or a heroin addict. I suspect this guy had been referred to a variety of shelters over time, but his underlying problems make those not much of a solution for him. Referring him to social work or a "place to go" likely wouldn't add much value here.

 

[prettyNURSEtoMD]

I am an ER nurse in a very high acuity ED and we do have our share of "frequent flyers" or "homeless" patients. We discharge these patients and let them go. If they are stable and medically clear...that's it. Now if it is extremely cold and/or "bad" weather they can stay in our lobby. We provide blankets for them etc. It is not unusual to see patients in the chairs asleep when I come on shift and I'm assigned to triage. We do have social services that provide resources for shelters in the city. As far as that nurse using profanity towards a patient is flat out wrong. And when you said the doctor was "shaking" him because he wouldn't wake up....I will say I've Sternal rubbed a patient a time or two because they are just completely knocked out. I think her delivery on waking the patient could have been better. But welcome to Emergency Medicine where you'll have a tendency to get burnt out and jaded.

 

[chillaxbro]

Damn none of the homeless people I work with are mentally ill
My experience is totally meaningless
My interviewers will be so bored 😡

 

[Straw Hat]

Not sure if this will be frowned upon but here's my say.

This doesn't surprise me much. Eventually once you're caring for these patients you'll realize you can't save them all. I'd try my best to get them the resources they need for help outside of the hospital. But most likely that person has been there 10+ times in the last month and is wasting everyone's time and money. Most homeless patients are here for 3 hots and a cot (giving them a tray of food is ok I guess, but do it once and be prepared for them to come back 20 more times… and it's such a waste of time and money to give a bed when they usually don't have a reason for it). Or people come for dilaudid. Or they're simply other types of frequent fliers that actually have no real medical reason to be here but try to get themselves admitted.

We have one lady who called 911 because she felt like her ECF wasn't meeting her needs. No medical emergency. She's readmitted 2-3 times every month getting breathing treatments q4h and PRN because she says she can't breathe while sucking down soda and hospital food. And she's max assist when moving her or getting her out of bed. She's noncompliant. Has a trach she actually doesn't even need. Takes the inner cannula out and sets it on the bedside only for us to have to put a new one back in. Oh and we already put a new one in an hour ago. Her ECF is fine, she just wants a change of scenery and around the clock care. If I ever become a physician or midlevel provider, I'll always keep in the back of my mind my experiences and those of other nurses. They put up with a lot of frustrating patients like this on a daily basis so please be mindful.

But anyways, talk about a waste of time and resources that could be better spent. I've definitely wanted to curse people like this out but I think that's unprofessional. But there will certainly be times where you'll want to. You feel bad about their treatment now but once they become your patients and you have the responsibility of caring for other patients that actually have a chance to get better… well it's a sad reality of healthcare at this time but you're going to get frustrated, disappointed, etc. Eventually you have to prioritize how you invest your passion/feelings. You definitely become jaded. But this is an extremely important protective mechanism. If you invest too much of the mentality you have now into your practice, you'll burn out fast. But don't worry, you learn all this as you go in clinical and practice.

 

[mehc012]

What they've said. ^^^
If you want hospitals to become responsible for the post-discharge conditions of every patient, they'd better start getting a LOT more money, STAT. Because, of course, if they did manage to successfully place people post-ER visit, they would quickly become the main avenue for all people needing social care.
A patient's social situation is considered when making the discharge decision...given the patient's lifestyle, is their current illness something that can be safely handled if they comply with the resources provided to them? (If they're mentally ill, their likelihood of compliance is also considered). We have definitely admitted people to the hospitalists apologizing that 'this could probably be managed outpatient, but the social worker has gone home and we couldn't get a shelter bed so I am concerned about discharging them'. We admitted a non-homeless man once because his mental illness made us uncertain that he would care for his perfectly manageable GSW at home (he ripped the bandages off his wound and flailed around until he got blood all over the damn room...it was too bad, really, because he might have been a candidate for digit-saving surgery if there were a good possibility of decent post-op management at home). We have also discharged people back to the street, many times. So does the other hospital in our area (which I know for a certainty as a few of our patients routinely catch ambulances from the parking lot of their hospital to ours on a whirlwind tour session).

 

[AlexMack12]

I work in an inpatient psychiatric unit and have worked with many patients with mental illness and/or substance abuse problems (which can be considered a subset of mental health disorders), some of whom are undomiciled.

Some people do not qualify for public housing due to criminal records. (This is certainly not to suggest that "homeless people are criminals." Rather, many people with significant criminal histories have an increased risk of having a difficult time finding housing). More than a few of our patients had stable housing but did not like their current arrangements and did what they needed to do to get admitted to the hospital for a chance at being discharged to "better" accommodations. Still others appear to be homeless (disheveled, unkempt, poor ADLs, sleeping on the street) but are later found upon admission to have residences; their mental health disorder has often played a role in this.

This is NOT in any way to excuse what appears to be unprofessional behavior by clinicians. Also, it is not to suggest that all patients can be categorized into the above groups-there are many, many people who are undomiciled and do not receive services they need, and it's truly a heartbreaking tragedy. However, for those wondering about what hospitals can do for patients that are (or appear to be) undomiciled, it's important to consider that for some patients, there may be more to the story than meets the eye.