When the Emergency Department is Home
Emily Nguyen
“I don’t know, I don’t know,” the patient mumbled. He kept shrugging and shaking his head, avoiding eye contact with the resident who was interviewing him. He was slumped in his chair. “It just hurts all over,” he said again, as he gestured towards the right side of his body. He made a big sweeping motion with his arm to show us. Was he indicating his leg? His abdomen? Whenever he motioned, he showed us a different body part.
The emergency department was noisy as usual, with nurses and therapists squeezing behind us to get by. The rooms were full, so the man we were interviewing was parked in a chair in the middle of the hallway. A first-year resident, a nurse, and I, a medical student, formed a wall around this man. He looked small in his baggy jeans and sweatshirt, and he seemed even smaller from my view looking above him. I wanted to kneel to see him at eye level, but the resident I was shadowing was standing, so I continued to stand too.
The resident persisted in his unfalteringly chipper voice, “Well, for me to help you, Sir, we must know exactly what happened. Do you know if you hit your head when you fell? Try to remember.” The patient repeated that he did not know what happened, and then asked when he could get some food. I was getting increasingly uncomfortable. The resident kept trying to rephrase the same questions to get more information about this patient’s reported fall, but I knew he was going to get the same response from this man despite his sincere efforts. The man just wanted food. I thought, could we just give him one of the sandwiches from the emergency department fridge and be done with it? It was agonizing to continue questioning him in the busy hallway.
The resident had finally given up trying to get a history from this man, so I followed him back to the nursing station where he stuttered out to the attending physician that he thought we should order an x-ray or a CT scan to make sure there was nothing serious going on. The attending asked, “How far do you want to go with this? Does this patient’s story match up with what is going on here?” I felt embarrassed observing this encounter to begin with, and now the attending physician’s evaluation of the resident’s decision-making was making me feel embarrassed for the resident. “Well, uh, you know, I just do not want to let my, uh, biases get in the way of my medical decision-making. You know what I mean?” I knew what he meant. Not once did anyone mention the word ‘homeless’ in conversation to describe the man in the sweatshirt for fear of sounding biased, but we all knew that he was clearly struggling.
The next morning, the weather was cold and rainy with freezing temperatures. I wore my earmuffs on the walk to the hospital that morning, wishing my walk was not so far, when I passed by someone in a sleeping bag under a bus stop, unfortunately not an uncommon sight in Washington, DC. He was wrapped up tightly in his sleeping bag; I could not see any part of his body. The sleeping bag was soaking wet. Water dripped down to join the puddles on the wet sidewalk where this person’s feet were propping up the sleeping bag. I shivered thinking about how cold it must be, to be wrapped up in a wet sleeping bag in this weather. I thought back to the patient in the emergency room the previous evening, thinking about how cold he must have been outside. His sweatshirt had been big, but not warm enough to withstand the cold and rain. I considered what it must be like to be a patient who must undergo a barrage of invasive questions and tests to get a meal or to have a dry bed to sleep in.
The Housing First approach to homelessness advocates the need to provide individuals with permanent housing primarily, rather than using a stepwise approach with an end goal of securing housing. This approach has been proven to save money for communities, decrease interactions with law enforcement, and decrease the amount of time unhoused people spend in the hospital. In DC, where I study, local organizations, such as Pathways to Housing DC, use the Housing First model to help people who are experiencing chronic homelessness. Pathways to Housing DC assists its clients with finding stable housing first, and then each client is matched with a support team that can provide client-centered wraparound services including but not limited to psychiatric care and addiction counseling. This model of providing permanent housing first has received bipartisan support and has shown itself to be the most successful way to keep people housed and on a path to recovery. For example, Pathways to Housing DC has proudly been able to keep at least 89% of its clients, who were previously considered ‘treatment-resistant,’ permanently housed.
Please — if you work in an emergency department, make yourself familiar with the housing policies of your local community. With a concerted effort, it is possible to bring homelessness to functional zero in our community.
