Make Hippocrates proud of you!

Charles is a stubborn man in his upper 80s.  He lives alone in a ranch style house and gets around in a wheelchair that is leashed to his bedroom by a very long oxygen tube that often gets tangled as he rolls from room to room.

He's grumpy and never tells people anything about his health.  He's not interested nor ready to get help for a noticeable difficulty with breathing that started a few days ago.  Determined to keep going in his independence, his breathing shallows to the point that he gets dizzy upon any exertion.  Still determined to not call for help, he struggles to stand up to put on his sweater that is on a hook at the top of his basements steps.  It's more effort than his ailing body can absorb.  He passes out, falls down the steps and lays there until his son stops in for a random visit the next morning.

Finding his dad at the bottom of the steps urine-soaked and soiled, the son calls 911.  The ambulance, medics, and police arrive and take him to the hospital for care of his obviously broken wrist and lower leg.  At the hospital, it's also discovered that he has very advanced pneumonia which the doctors immediately recognize as the primary cause of Charles having passed out and fallen.

Casts are placed around the broken bones and antibiotic therapy is immediately provided to clear up the pneumonia.  About a week later, Charles is transferred to a nursing home for therapy and rehab of his broken bones and to monitor is clearing pneumonia.  

**********

Hannah is a delightful and stubborn woman in her 20s.  She lives on the streets, gets around by foot and finds food for the day at local outreach ministries.  She's been on the street for years as she does what she needs to do in her life as a homeless woman with Substance Use Disorder in its addicted phase.

She's settled into a routine of what drug combinations she prefers and has avoided overdose until recently.  For reasons that she can't identify, she's overdosed four times in two weeks and[1] been revived by Narcan each time.  At her third overdose, she was taken to a very local hospital where the nurse told her to get out.  Hannah returned to the street and overdosed for her fourth time four days later.  This time, she fell and caused enough of a bodily injury that she had to be taken to a more advanced local hospital that could handle her injuries.  And that the hospital did. 

They tended to her injuries which were the direct result of falling as she overdosed from her use of street drugs.  While fully aware of her use of drugs, the hospital, according to their policy, did not treat her symptoms of dope sickness that were increasing by the hour and day.  "We don't detox patients on this floor.  Detox is done in a different unit." They explained to me.

With four days of medical care for her injuries and no real care for her dope sickness, to relieve that sickness, Hannah signed out AMA[2], made her way to Kensington, consumed her first bag of medicine and began to…

As you read this, Hannah's story is unfolding on the street in a way that could oh so easily march her right into her fifth and final overdose.

**********

Charles' fall and resulting broken bones were the result of passing out due to insufficient breathing caused by pneumonia.  The hospital treated his injuries and his illness simultaneously.

Hannah's fall and resulting injuries were the result of passing out due to overdose caused by street drug use.  The hospital treated her injuries and would have treated her withdrawal issues only upon transfer to the detox unit.

Charles was transferred to a nursing home where his healing continued under the watchful eye of professionals who have pledged their careers to the Hippocratic Oath.

Hannah transferred herself to the street since it's far faster to do a quick date for the money to buy a bag of drug and relieve her dope sickness than it is to wait a few more days to be transferred to the "proper unit."

In a few weeks, Charles will be heading home, this time with arrangements for a daily visit by a community nurse.

Hannah, well, Hannah might be dead by now.  I don't know.  She may be deceased by an overdose that could have been avoided if the hospital had treated her in her entirety and not symptom by symptom. 

Now that Charles is home, his son visits him on a daily basis and asks him why he's so stubborn.  They laugh about it a bit as Charles agrees to be more honest about his health issues.

My concern for Hannah is that the day will come when her cousin will hold Hannah's youngest child in her arms as that child looks down at Hannah and ask "Why is my Mommy asleep in that pretty box?"

**********

When a patient of Substance Use Disorder is admitted to a hospital for treatment of any injury or illness, that hospital MUST do everything within modern scientific understanding to provide comfort and relief of withdrawal symptoms while they attend to the illness and injury. 

Make Hippocrates proud of you!

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[1] , because she injects in public, has been seen overdosing and

[2] Against Medical Advice

Hippocratic Oath: Modern Version

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

—Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

The "Cure" Is Worse Than The "Problem."

Today, for the first time in the three years that I have been visiting the people on the streets of Kensington, a new and disturbing thought hit me…

While acknowledging and being thankful for pockets of success…

Sadly, the inept[1], unprofessional, cruel, incompetent, non-respectful, etc. etc, etc. responses by people who have pledged themselves to integrity in government or their medical careers to Hippocrates have largely been an utter failure in making better to any real degree this national tragedy within homeless addicted people diagnosed with Substance Use Disorder.

The men and women of SUD themselves, in their attempts to maintain self developed safety guidelines had been doing an amazing job.  For example, 

To the untrained eye, a bunch of people living in tents under a bridge are labeled “addicts” “whores” “moral incompetents” and other uneducated, painful, derogatory references.

Looking more closely, however, you would have discovered a gathering of people bound together by an officially recognized disease of SUD and who are in the addicted phase thereof.   In the absence of respectful, timely medical treatment at the Medicaid level of care, they have no real choice other than to continue to take their "medicine".  

In the absence of being able to find w-2 type employment they must resort to various forms of less dignified ‘service jobs’.  For the men: this might include hauling loose metal to junkyards to redeem for cash or for the ladies: renting their bodies for, well, you know…

They gather in these communities for one overriding reason.  Their needed medicine can kill them.  They know this.  So as to avoid this possibility as much as can be, they gather together to inject.  If one person starts to overdose, someone else will see this happening and provide Narcan.  In so doing they save each other’s lives.  

The number of saves of homeless SUD patients by other homeless SUD patients will shock you.  153… 76… 43… 25…  These are real numbers presented to me by four street residents.  That’s a lot of non-dead relatives and funerals that didn’t happen.

By being in community, they maintain their own grassroots level overdose prevention sites.  Well, we need to put that in past tense.  These coherent communities were deleted by the City of Brotherly Love in their efforts to “clean up” the problem of “addicts” injecting in the open.

The end result has been an increase in the number of orphans as their Moms/Dads or both have overdosed in the solitude of an abandoned house, back alley or other such settings

and

Moms and Dads of these men and women who suffered from SUD who have had to bury their daughters and sons.  

There are many other examples of how these medical patients have been failed by those who were pledged through oaths of office and Hippocrates to serve, protect and do no harm.

Judicial practices plant these medical patients in cells designed for criminals for months on end and with no rehabilitation during this time of “mental rot.”

Subsidized housing offers protection from the street but increases the likelihood of solitary injecting in rentals that are not abandoned but largely slumlord managed.  

When any of these Medicaid reliant SUD patients decide they have had enough, they must climb what I’m calling “Medicaid Mountain” so as to get to their personal path of healing.  Most don’t make it as they navigate narrow ledge trails on the sides of this mountain through bureaucratic procedural obstacles and attitudes of supposed professionals who they encounter along the way.  

So, you may be asking…  What was that disturbing thought that I had earlier today?  

Given that the homeless men and women of SUD had already established their own Overdose Prevention Sites and were saving each other at astounding rates and given the low quality of care that these children of God receive on the narrow cliffs of Medicaid Mountain from the larger community, it’s sadly safe to concur that the current ‘cure’ for the problems associated with SUD in its addicted and homeless phase is much worse than the "problems" themselves.

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[1] not in keeping with what is right or proper for the circumstances

And She Slept... Two Years Ago Today

Dear "Diane,"

Who would have ever known, other than our LORD, that you would be unwittingly and unknowingly going home to Him a year and almost 7 months after you slept on a sidewalk tucked inside a donated quilt?

You were and are loved by so many people who had the joy of knowing you.  Mom, Dad, Sisters, Step Dad, best Friend and extended Family[1] love and adore you to this day and for the remainder of their lives. 

You gave them two precious living memorials to your life.  May God Almighty be with those memorials and teach them His ways as you would have done as the healthy Christian Mom who you so very much wanted to be.

You wanted healing.  You sought healing.  For as much as you wanted and sought while on this earth, it was not to be found here for reasons that need societal correcting.  You did find healing within the loving eternal presence of your Savior.  

From "Diane's" letter to me 10 days before she went Home.

Day by day, we mourn our loss.  Through our tears that miss your presence, your hug, your naturally raspy voice, we do what we can to celebrate in knowing that you did find healing when you met Face to Face with your Ultimate Healer.

We miss you.  We celebrate you.  We worship our LORD with you on earth as you do in His actual factual Presence in Heaven. 

We seek rest in knowing that your earthbound battle is over.  We do what we can to know that you rest in the presence of the King of Kings and LORD of LORDS.  We seek to sleep at night knowing that you sleep in the bliss of Heavenly eternity.  

And She Slept 

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[1] and a judge

Damaged Determination

Over my shoulder, as I was heading back to my car, I heard a soft-spoken whimper...

"Banana Man?" 

Turning around, I wondered who had just called out in this quiet tear toned soft voice of despair.  I saw a human-shaped form under a black quilt, walked over to it and saw some long hair and enough of an eye to realize this was one of the ladies of the community.  She spread the opening of the quilt just enough for me to see her eyes and her eyes only.

"'Rose' is that you?" 

She spread the opening of that old black quilt a bit more and there she was.  With tears running down her cheeks just as they had upon our first conversation, she shared with me her agony of despising her current life situation, wanting life to be better and asking me to take her to detox NOW.

As she began to cry harder than perhaps I’ve ever seen her do so, she leaned into me for a hug.  It had been about 6 weeks since we’d seen each other.  During that time, we had one brief Facebook chat.  

As she began to sink into my chest, I showed her that I was still wearing the bracelet that she had slipped onto my wrist when she asked me to love her as a daughter.  She cried harder. We held each other, there on that sidewalk as would any father and daughter[1] upon rediscovering each other in a daughter's agony.  Tears flowed from both of us.

After a few phone calls to develop a plan, we went to Gaudenzia for Detox.  It was determined that there might be something medical going on in addition to the obvious SUD[2] related issues.  We went to the hospital that they recommended for evaluation in the ER.  It was midnight before Rose was being taken to her room for admission to receive antibiotics for an infection, the specifics of which were still to be determined.

From our arrival at Gaudenzia to the moment of being lifted to her admission bed, Rose endured with grace and determination to see it through, her personal version of increasing dope sickness as the hours ticked by.  Shivers and nausea were followed by sweats and vomiting.  Determination to see her mission through to health and healing grew within her as did the pile of soiled linen in the corner hamper.  

For the next 36 hours, four of which I sat with her on Monday, she twitched and turned in the increasing discomfort of being treated for her infection and barely at all for her detox.

36 hours after being admitted, 40 hours after determining to be done with addiction, Rose signed out AMA[3] in obvious physical and spiritual agony, yelling at heroin - telling it to stay away from her and craving it at the same time.  

Rose is back on the street fully absorbed in addiction and free of her infection.  

Rose is a patient of SUD.  Her SUD was all but ignored and her infection, a condition brought on by her SUD and its associated state of homelessness was treated.  By treating the infection and not the SUD, the doctors and nurses of the hospital who are representatives of the Hippocratic Oath did one thing.  They helped Rose regain the strength that was being absorbed by infection and in so doing made her stronger for her to continue her life in addiction and homelessness.

SUD and the infection are both disease processes that should have been treated in totality and simultaneously.  By treating a secondary symptom of SUD - the infection - the Doctors within this hospital did not promptly address the main cause of the infection - SUD itself.

Damaged Determination

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[1] Reminder: This is an honorary relationship.

[2] Substance Use Disorder

[3] Against Medical Advice