Homeless psych dispo -WWYD?

[pandahunter]

Had a case recently with a homeless guy coming to the ED after being release from jail the same day asking for help because of a panic attack. He definitely was cogent and coherent enough that I didn’t think he was exhibiting any emergent toxidrome or withdrawal.

So I give him a rx for a couple Xanax because he supposedly lost his after his car was stolen while he was in jail. I give him some lorazepam in the ED. I offer to have him stay overnight in the lobby for the social worker to see him in the morning. He balks and says he needs to be hospitalized for his anxiety and asks to be admitted so he can have shelter and food, all while not meeting criteria fir a psych hold. Says I’m not treating his panic attack.

I get the vibe that he’s partially malingering and eventually almost forcefully discharge him with outpatient mental health resources. But I still feel guilty I didn’t do enough and can’t stop thinking about it. How would you guys have dealt with it? Would you guys have just brought him inside a crowded ER and let him sleep and give some food? I know there was a new California law regarding treatment of homeless patients a few years ago but I am also conflicted about turning my shop into a homeless shelter as we’ve had droves of patients coming in the middle of the night essentially asking for food. Anyway, I just wanted to get someone else’s take since I feel like a crappy doctor and a crappy person.

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[Rendar5]

Hydroxyzine. (no need for controlled addictive anxiolytics). No food at after midnight. Can stay in lobby til sun comes up...

not sure how Xanax would help his situation (well actually it would since it has street value) or psychiatric hospitalization. Outpatient mental health referrals and social work in am are helpful or at least better than nothing.

 

[southerndoc]

Agree with hydroxyzine if I give him anything at all. Care coordination would see him in the ER (we have 24/7 availability) and he would be discharged (how he chooses to exit the ER is up to him, but he's exiting).

 

[GeneralVeers]

Discharge immediately to waiting room. This one requires no thought at all.

 

[thegenius]

Had a case recently with a homeless guy coming to the ED after being release from jail the same day asking for help because of a panic attack. He definitely was cogent and coherent enough that I didn’t think he was exhibiting any emergent toxidrome or withdrawal.

So I give him a rx for a couple Xanax because he supposedly lost his after his car was stolen while he was in jail. I give him some lorazepam in the ED. I offer to have him stay overnight in the lobby for the social worker to see him in the morning. He balks and says he needs to be hospitalized for his anxiety and asks to be admitted so he can have shelter and food, all while not meeting criteria fir a psych hold. Says I’m not treating his panic attack.

I get the vibe that he’s partially malingering and eventually almost forcefully discharge him with outpatient mental health resources. But I still feel guilty I didn’t do enough and can’t stop thinking about it. How would you guys have dealt with it? Would you guys have just brought him inside a crowded ER and let him sleep and give some food? I know there was a new California law regarding treatment of homeless patients a few years ago but I am also conflicted about turning my shop into a homeless shelter as we’ve had droves of patients coming in the middle of the night essentially asking for food. Anyway, I just wanted to get someone else’s take since I feel like a crappy doctor and a crappy person.

Kick him out. You can't solve social problems. You are not hired to solve social problems. It was clear from your description that he didn't even come close to having a medical or psychiatric emergency. Don't feel burdened to help every single person who comes into the ED. 50-70% of the crap we see should just turn around and walk out the door.

 

[RuralEDDoc]

Try not to feel bad about that encounter. It’s not your fault and you can’t fix the system or the patient.
I once had a homeless wheelchair bound double amputee veteran scream at me for discharging him when he wanted a social admission. That was tough and I felt bad but it was the right call then and I would do it again.

 

[Mad Jack]

It would be unethical to give him a bed while not meeting criteria when I've got actual patients with severe mental illness that need one. Social workers in the ER can provide him with resources, hydroxyzine for the road, if it is a particularly cold night he can shelter in the lobby. It isn't the job of the mental health system or health system in general to treat homelessness and hunger. Our community actually has pretty good resources for people like this though, we've got good shelter and homeless kitchen availability, as well as a resource center that is open 16 hours per day, so you just point someone at these resources and see if social work can provide anything else.

 

[clibby]

If we gave every homeless patient a bed, then how would we room patients to find the STEMI, stroke, SBO, etc in the waiting room. I wish I had a better solution, but providing resources, a blanket, a meal, and +/- medications if indicated is the best you can do to be fair to the rest of the patients that need to be seen.

As a side note, why is anyone using Xanax for anything other than isolated panic attacks in reliable patients. If it were up to me, we would remove it from the market. Too high abuse potential with an efficacy profile that is bested by so many other options!

 

[southerndoc]

If we gave every homeless patient a bed, then how would we room patients to find the STEMI, stroke, SBO, etc in the waiting room. I wish I had a better solution, but providing resources, a blanket, a meal, and +/- medications if indicated is the best you can do to be fair to the rest of the patients that need to be seen.

As a side note, why is anyone using Xanax for anything other than isolated panic attacks in reliable patients. If it were up to me, we would remove it from the market. Too high abuse potential with an efficacy profile that is bested by so many other options!

It's worse in California. IIRC, admitted homeless patients cannot be discharged until housing arrangements have been made. I don't think it applies to patients discharged from the ER.

 

[namethatsmell]

Gets discharged 101% of the time.

But it's OK to have internal discord about stuff like this from time to time. Shows you still care and aren't completely burned out.
Our healthcare "system," along with society's view of what it should do for them, is f*cked up. While corny, the old mantra still applies: "Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference."

 

[WilcoWorld]

Had a case recently with a homeless guy coming to the ED after being release from jail the same day asking for help because of a panic attack. He definitely was cogent and coherent enough that I didn’t think he was exhibiting any emergent toxidrome or withdrawal.

So I give him a rx for a couple Xanax because he supposedly lost his after his car was stolen while he was in jail. I give him some lorazepam in the ED. I offer to have him stay overnight in the lobby for the social worker to see him in the morning. He balks and says he needs to be hospitalized for his anxiety and asks to be admitted so he can have shelter and food, all while not meeting criteria fir a psych hold. Says I’m not treating his panic attack.

I get the vibe that he’s partially malingering and eventually almost forcefully discharge him with outpatient mental health resources. But I still feel guilty I didn’t do enough and can’t stop thinking about it. How would you guys have dealt with it? Would you guys have just brought him inside a crowded ER and let him sleep and give some food? I know there was a new California law regarding treatment of homeless patients a few years ago but I am also conflicted about turning my shop into a homeless shelter as we’ve had droves of patients coming in the middle of the night essentially asking for food. Anyway, I just wanted to get someone else’s take since I feel like a crappy doctor and a crappy person.

Take it from a guy with a bleeding heart who will bend over backwards for people - You gave good care.

 

[Mad Jack]

If we gave every homeless patient a bed, then how would we room patients to find the STEMI, stroke, SBO, etc in the waiting room. I wish I had a better solution, but providing resources, a blanket, a meal, and +/- medications if indicated is the best you can do to be fair to the rest of the patients that need to be seen.

As a side note, why is anyone using Xanax for anything other than isolated panic attacks in reliable patients. If it were up to me, we would remove it from the market. Too high abuse potential with an efficacy profile that is bested by so many other options!

Xanax is a plague upon our nation. It should absolutely be removed from the market. There's plenty of other short-acting benzos that don't have its unique addiction potential

 

[Mad Jack]

It's worse in California. IIRC, admitted homeless patients cannot be discharged until housing arrangements have been made. I don't think it applies to patients discharged from the ER.

I would have a while unit full of people that were perfectly fine but had no place to go if this were the case in my state

 

[Groove]

Discharge. Security escort off the premises. I would give no prescriptions but I would print out a list of outpatient shelters and homeless resources. If social work were available during regular business hours I might inquire for their assistance in setting this guy up with something if I were feeling generous. The minute the word gets out on the street that you are "sheltering" homeless, you're going to be overrun and abused. Your job is to treat the sick and the dying, not provide humanitarian relief. Let the shelter organizations do their job while you do yours.

My dad likes to talk about winters where the surgery residents would drive around and pick up homeless off the street and place them in hospital wings, feeding and clothing them for days so they wouldn't get gangrene. Well, those days are long gone.

 

[southerndoc]

I would have a while unit full of people that were perfectly fine but had no place to go if this were the case in my state

I remember reading that the problem became so bad that hospitals opened up their own shelters. They can't discharge them to the streets from the hospital, but they can from a shelter. Hospital -> shelter -> street.

 

[dadaddadaBATMAN]

Had a case recently with a homeless guy coming to the ED after being release from jail the same day asking for help because of a panic attack. He definitely was cogent and coherent enough that I didn’t think he was exhibiting any emergent toxidrome or withdrawal.

So I give him a rx for a couple Xanax because he supposedly lost his after his car was stolen while he was in jail. I give him some lorazepam in the ED. I offer to have him stay overnight in the lobby for the social worker to see him in the morning. He balks and says he needs to be hospitalized for his anxiety and asks to be admitted so he can have shelter and food, all while not meeting criteria fir a psych hold. Says I’m not treating his panic attack.

I get the vibe that he’s partially malingering and eventually almost forcefully discharge him with outpatient mental health resources. But I still feel guilty I didn’t do enough and can’t stop thinking about it. How would you guys have dealt with it? Would you guys have just brought him inside a crowded ER and let him sleep and give some food? I know there was a new California law regarding treatment of homeless patients a few years ago but I am also conflicted about turning my shop into a homeless shelter as we’ve had droves of patients coming in the middle of the night essentially asking for food. Anyway, I just wanted to get someone else’s take since I feel like a crappy doctor and a crappy person.

I would absolutely not write for xanax in an unverifiable story about it being “stolen.” It’s another way to say ran out before script was finished. Maybe it was, maybe it wasn’t, but that has to be discussed with the original prescriber so that if it happens every month they know it.

I would not admit either. It’s not what the hospital does, especially not when people are boarding due to covid

The most I would give this guy would be Librium to prevent withdrawal seizures on his return visit, and it wouldn’t be a script. Comes with the caution that it lasts a long time (half life around 24 hrs) so if they drink or use other stuff bad things can happen. Even this I would do with caution, but I find it is less satisfying for people looking for a bdz high

 

[turkeyjerky]

That guy was manipulating you.

 

[deleted547339]

It's worse in California. IIRC, admitted homeless patients cannot be discharged until housing arrangements have been made. I don't think it applies to patients discharged from the ER.

Im pretty sure it is required of ED patients as well. I thought I read a paper or abstract or something that was studying it.

 

[Groove]

Im pretty sure it is required of ED patients as well. I thought I read a paper or abstract or something that was studying it.

Man, I hope not. Can you imagine not being able to discharge a homeless patient until shelter had been obtained for them?! That's insane. Your ED would start to look like one of those San Francisco downtown tent camps after awhile. Feces and needles on the ground. Gotta love the California politicians.

 

[DrDrummer]

Hopefully the messages posted thus far will convince you that your approach was very reasonable, and if anything erred on the side of compassionate. I would not have prescribed Xanax or given Xanax and can think of maybe one time in the last five years I gave someone a dose. Yes to hydroxyzine, brief mindfulness meditation/ breathing training, referral to local mental health resources and shelter resources, possibly a check-in with the social worker if it was during daytime hours. Once they start talking about demands to be admitted for their anxiety or to "detox" or start declaring vague passive suicidal ideation when it's time for discharge, trying to remain compassion-focused becomes much more difficult, particularly in these resource-strained and generally otherwise-stressful times.

 

[DrDrummer]

Im pretty sure it is required of ED patients as well. I thought I read a paper or abstract or something that was studying it.

News: California Law Setting Discharge Rules for Homeless... : Emergency Medicine News

An abstract is unavailable.

journals.lww.com

This summarizes it fairly well. We do not have to find housing for homeless patients. The law requires that they be discharged to a safe and appropriate location.

From the actual law:

(4) Unless the homeless patient is being transferred to another licensed health facility, the policy shall require the hospital to identify a postdischarge destination for the homeless patient as follows, with priority given to identifying a sheltered destination with supportive services:
(A) A social services agency, nonprofit social services provider, or governmental service provider that has agreed to accept the homeless patient, if he or she has agreed to the placement. Notwithstanding paragraph (2) of subdivision (k) and subdivision (l), the hospital shall provide potential receiving agencies or providers written or electronic information about the homeless patient’s known posthospital health and behavioral health care needs and shall document the name of the person at the agency or provider who agreed to accept the homeless patient.
(B) The homeless patient’s residence. In the case of a homeless patient, “residence” for the purposes of this subparagraph means the location identified to the hospital by the homeless patient as his or her principal dwelling place.
(C) An alternative destination, as indicated by the homeless patient pursuant to the discharge planning process described in paragraph (3). The hospital shall document the destination indicated by the homeless patient or his or her representative.

 

[GeneralVeers]

Look Glenn We're Saved! - South Park (Video Clip) | South Park Studios US

 

[DeadCactus]

There’s a wide gray area between treating someone in need with contempt and not allowing others be hurt by the demands of the squeakiest wheel. I think you are well within the confines of providing compassionate and respectable care. We can’t fix the system on shift and we can’t force patients to make optimal use of the system that exists. On shift, we can only operate within the confines of what is there and help patients navigate it.

 

[Rekt]

Had a case recently with a homeless guy coming to the ED after being release from jail the same day asking for help because of a panic attack. He definitely was cogent and coherent enough that I didn’t think he was exhibiting any emergent toxidrome or withdrawal.

So I give him a rx for a couple Xanax because he supposedly lost his after his car was stolen while he was in jail. I give him some lorazepam in the ED. I offer to have him stay overnight in the lobby for the social worker to see him in the morning. He balks and says he needs to be hospitalized for his anxiety and asks to be admitted so he can have shelter and food, all while not meeting criteria fir a psych hold. Says I’m not treating his panic attack.

I get the vibe that he’s partially malingering and eventually almost forcefully discharge him with outpatient mental health resources. But I still feel guilty I didn’t do enough and can’t stop thinking about it. How would you guys have dealt with it? Would you guys have just brought him inside a crowded ER and let him sleep and give some food? I know there was a new California law regarding treatment of homeless patients a few years ago but I am also conflicted about turning my shop into a homeless shelter as we’ve had droves of patients coming in the middle of the night essentially asking for food. Anyway, I just wanted to get someone else’s take since I feel like a crappy doctor and a crappy person.

Discharge immediately to waiting room. This one requires no thought at all.

Yeah this is really confusing. Did OP not do EM training? I see this case like every day. "I'm sorry, but I do not prescribe narcotics/benzodiazepene's for this."

And then you discharge them. The emergency department isn't a restaurant.

 

[WilcoWorld]

My dad likes to talk about winters where the surgery residents would drive around and pick up homeless off the street and place them in hospital wings, feeding and clothing them for days so they wouldn't get gangrene. Well, those days are long gone.

That's probably more cost-effective than treating the gangrene. And it would be even better to have social workers doing this.

 

[WilcoWorld]

I remember reading that the problem became so bad that hospitals opened up their own shelters. They can't discharge them to the streets from the hospital, but they can from a shelter. Hospital -> shelter -> street.

Very interesting how well-intentioned but poorly executed law leads to poorly executed "solutions".

 

[WilcoWorld]

There’s a wide gray area between treating someone in need with contempt and not allowing others be hurt by the demands of the squeakiest wheel.

This is a very important distinction that I think is woefully under-appreciated in our public discourse around this and related issues.

 

[EM_kindaguy]

This is a misunderstanding of how the California law is being used - The California law, in practice, means that we have to provide every person who is homeless with RESOURCES about shelters and housing, not that we have to literally find a spot and transfer them to it. It's truly not nearly as alarmist as it sounds.

 

[BoardingDoc]

This is a misunderstanding of how the California law is being used - The California law, in practice, means that we have to provide every person who is homeless with RESOURCES about shelters and housing, not that we have to literally find a spot and transfer them to it. It's truly not nearly as alarmist as it sounds.

That is incorrect. The law SB 1152 states that unless the patient is being transferred to another hospital, they are required to be discharged (and be provided with a way to get there) to the following:
1: A shelter which has agreed to take the patient
2: The patient's residence. If they say they identify where they normally stay (whether that's a house, tent, street corner, whatever) that works.
3: Somewhere that the patient wants to go

It also states that the patient must be given a meal and weather appropriate clothing.

The hospital also needs to provide transportation to one of those 3 above options provided that it's within 30 minutes or 30 miles of the hospital.

In short, if the patient states "I have nowhere to go," the hospital is in fact required to find a shelter AND guarantee that the shelter will take them. Whether this actually happens, I have no idea as I don't live in CA. The law I linked above certainly seems to say that's what is supposed to happen though.

 

[southerndoc]

That is incorrect. The law SB 1152 states that unless the patient is being transferred to another hospital, they are required to be discharged (and be provided with a way to get there) to the following:
1: A shelter which has agreed to take the patient
2: The patient's residence. If they say they identify where they normally stay (whether that's a house, tent, street corner, whatever) that works.
3: Somewhere that the patient wants to go

It also states that the patient must be given a meal and weather appropriate clothing.

The hospital also needs to provide transportation to one of those 3 above options provided that it's within 30 minutes or 30 miles of the hospital.

In short, if the patient states "I have nowhere to go," the hospital is in fact required to find a shelter AND guarantee that the shelter will take them. Whether this actually happens, I have no idea as I don't live in CA. The law I linked above certainly seems to say that's what is supposed to happen though.

I'm sure each county has variable enforcement of it.

 

[d2305]

Haldol will calm his anxieties if you must.

 

[pandahunter]

Yeah this is really confusing. Did OP not do EM training? I see this case like every day. "I'm sorry, but I do not prescribe narcotics/benzodiazepene's for this."

And then you discharge them. The emergency department isn't a restaurant.

Yes I did em training. It’s just difficult not to think about it when I’m calling for security to quite literally drag a person off the premises while he’s crying saying I’m not helping people. Sorry if that makes me untrained in your eyes.

 

[lp430]

We can help some people some of the time, not all people all of the time. I've seen too many cases like this. Maybe I'm just numb to it now.

 

[GeneralVeers]

People in the ED will manipulate you through your emotions. The homeless and borderlines are the worst for this. The key is to remain calm and implaccable.

It's like being a Jedi, control your emotions or to the Dark Side it will lead.

 

[thegenius]

Yeah this is really confusing. Did OP not do EM training? I see this case like every day. "I'm sorry, but I do not prescribe narcotics/benzodiazepene's for this."

And then you discharge them. The emergency department isn't a restaurant.

The ER is like Burger King. “Have it your way”

 

[DeadCactus]

Yes I did em training. It’s just difficult not to think about it when I’m calling for security to quite literally drag a person off the premises while he’s crying saying I’m not helping people. Sorry if that makes me untrained in your eyes.

I say kudos on not losing that part of you that cares about people even if they are difficult or struggling.

 

[Tenk]

The same left click that you prescribe the vistaril is the same left click that you hit the discharge button.

 

[d2305]

Try not to feel bad about that encounter. It’s not your fault and you can’t fix the system or the patient.
I once had a homeless wheelchair bound double amputee veteran scream at me for discharging him when he wanted a social admission. That was tough and I felt bad but it was the right call then and I would do it again.

If he was service connected, he made enough disability each month to pay a mortgage or rent. They make over $40k a year tax free.

 

[nexus73]

Agree with care provided, though would recommend avoiding controlled substances. From a classical conditioning standpoint, giving patients drugs like Xanax (or giving inappropriate admission, food, opioids, other resources, etc) can instill a deep behavior pattern bringing them back to the ED to inappropriately get needs met. Humans are simple like rats pushing the lever for cocaine.

 

[GeneralVeers]

Agree with care provided, though would recommend avoiding controlled substances. From a classical conditioning standpoint, giving patients drugs like Xanax (or giving inappropriate admission, food, opioids, other resources, etc) can instill a deep behavior pattern bringing them back to the ED to inappropriately get needs met. Humans are simple like rats pushing the lever for cocaine.

Correct. The "feeding the bears" analogy is quite appropriate. The chronic malingering psych guys are astonished when I won't admit them for the 4th time in a week for "feeling suicidal". I document they've already had multiple psych evals, and discharge them. Most doctors just rubber stamp the psych holds, which has programmed them to say the right things to get an easy hotel stay.

 

[FlowRate]

One of my favorite lines that I liked to drop into consult notes on malingering folks in the ED:

"Psychiatric hospitalization would increase the patient's dependence on the mental health system for needs which he should learn to meet via appropriate mechanisms, such as homeless shelters. Furthermore, inpatient days do not count toward the 'days homeless' (in MA) required for Section 8 housing."

Well, I had an even better way of phrasing it but haven't had to write one of those notes in a while.

 

[hebel]

If he was service connected, he made enough disability each month to pay a mortgage or rent. They make over $40k a year tax free.

Yeah, as a resident a lot of my disabled VA patients were making more than me.