Attending to the Daily Emergencies Beyond the Emergency Dept.

I’m checking out a smart phone, in the back of a cop car, while wearing Kevlar. The photo is of the dynamic duo and it’s Halloween; they fittingly are a superhero team. Adam, the cop and Shane, the paramedic, have been doing their respective jobs for a long time and they know Indianapolis and the people they serve well. Today they are showing me the health outreach portion of what they do for the Shepherd organization. The Shepherd organization which provides faith based social services in their near east-side Indianapolis neighborhood.

We are checking on a few citizens in the area and delivering boxes of food for the holidays. We drove around, knocked on doors, and entered homes (some that I didn’t realize were occupied from the outside). Unlike the white washed Emergency department environment and gowns that I usually see our patients in, completely devoid of context, I met them in their own clothes, in their own home, amongst their belongings and usual ways of life.

What does this have to do with my all-consuming current walk in life as an Emergency department resident?

I will tell you that I saw how some of our most “difficult” patients live and realized how difficult their circumstances are. I recognize it’s not fair of me to call patients difficult, but being honest, most health care providers will know immediately what I mean. Whether it’s medicine noncompliance, difficulty with instructions or follow through, lack of (by your judgment) sensibility, lack of resources that make getting better near impossible – these people have them and you’ll be hard pressed to “fix” them. It’s a sense you get in the room as you take a history that things are not going well beyond this current chief complaint. Your eyes glaze, good luck, and call social work (if you’re lucky enough to have them in your shop).

Like a vital sign which clues you in to a patient’s condition, their living conditions bring a lot of context to their situation. My mentor from Univ. of North Carolina, Dr. Jane Brice, said about her initial career as a paramedic that seeing how people lived was one of the things she missed most when she became an Emergency physician. (She also said that if being a doctor was half as fun as being a paramedic she would continue to do it. She joked, it has been exactly half, and she currently sits as Chair of the Dept. of Emergency Medicine at UNC). I understand this better now.

We entered one house to find three adults bed bound, collectively wheezing, their oven door open for heat, while a busted pipe in the ceiling of the front room dripped making everything there unusable and black with mold. We checked that they had their current COPD medications and inhalers. One of the adults seemed to be more subjectively feverish. She would need a doctor to see her soon, but perhaps not in the ED unless worsening, so we called and arranged an outpatient visit for her to be checked out – a thought that had not occurred to the cluster of adults.

The next house we met “a usual” for the team, he frequently drinks and then calls the ambulance for suicidal ideation in the form of drinking himself to death. He gets carted to the ED more than weekly, sobers up, and returns home despite plenty of attempts to get him enrolled in other substance or psychiatric programs. Today he is sober and Adam and Shane are excited because he has had a record number of weeks without drinking and without any EMS runs. They banter back and forth and as they are leaving note that is he being a little sheepish. In the car they check the ambulance system records and it turns out that he had just called EMS the night prior. Immediately Shane grabs his cell phone and calls the man back to ask him what happened. Shane listens, he comments that he is a bit disappointed, and then reminds him to do his best, and they will check in again soon. Their relationship allows them to be honest this way. Adam and Shane have rounded up funds for him to go to rehab but he always says next month, for half a year now.

The last home is that of a young man and his family. Unfortunately, he came out of jail to find poor job prospects and when his cash dried up he chose to pay the minimum amount on his utility bills so the companies did not turn of his services rather than refilling his blood pressure medications. Just $5 more makes a difference in what he can afford monthly. He is not home today, he is working two jobs, as is his spouse. Luckily, he is getting his medicines through Shepherd and staying out of the hospital where he has had to go before due to such extreme blood pressure and downstream health effects. Before enrollment in the program, he had to leave against medical advice because if his fragile income dips, he risks losing utilities, and then his kids. Today just the children are home with a grandmother while both parents work. It is a school day and one kid was mildly ill this morning so none of them went which makes me cringe. One small chink in the chain and their lives go less than optimally. They are very excited to see the groceries for dinner.

I ask what Shane and Adams’ opinions of this work and if they get frustrated like we do in the ED sometimes. Shane said, the honest truth with these kinds of endeavors is that people are afraid to fail. I think about my interactions with difficult patients in the ED, I am more frustrated because I get the sense I am about to fail at fixing them like a good doctor should. No one said their problems were fixable, but how can they be mitigated and what should our role from the ED be in that process? I don’t have an answer but like I alluded to before, having the complement of social work in our department makes a difference.

I also think of the research I am currently helping with at Eskenazi looking at can mobile integrated health services reduce costly visits and admissions that might be preventable. We are afraid that by looking in to the numbers we will find the intervention to be statistically insignificant. However, today’s ride along I have to wonder, how insignificant is it when someone shows up with a box of groceries for you when you’re house bound? During the holidays, I am thankful that we have people out here beyond the Emergency Department doing these things. I am biased in hoping they are successful models of improving what we do in health care. Just knowing they are out there, providing what they do to people I see and cannot always help makes me feel better about my job in life.

Jennica Siddle MD, MPH

2nd year Emergency Medicine Resident

 

pictures courtesy of Shane Hardwick

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