Thanksgiving

I only had to work the morning this Thanksgiving, which was a signal improvement on last year. 

I spent the 2008's Thanksgiving at a rather elaborate celebration hosted by an old friend involving smoked turkey and a variety of other nice things, which was clouded for me by the inevitability of an 11:00 PM to 8:00 AM shift in the Emergency Department.  I wondered vaguely what the night was going to bring, imagining a torrent of gout exacerbations brought on by over-indulgence in purine-rich delicacies, punctuated by a predictable flow of alcohol-induced head injuries. 

I was surprised when I duly arrived at eleven, annoyingly sober and carrying a tupperware container of mixed leftovers, to find the place nearly deserted.  The expected battalion of portly men with swollen toes were nowhere to be seen.  The monotony was interrupted by a few bizarre traumas - a seventeen year old boy was brought in around two-thirty after falling from a tree in a local park, although what he had been doing there was never clarified to my satisfaction; and another young man came in with a comparatively minor gunshot wound he received after the hapless reveler he had been threatening wrested his gun away from him - but other than that things were extremely slow.  I think I spent a full hour watching an ED attending de-frost the departmental freezer by excising large slabs of ice using a wound-irrigation rig filled with warm tap water.

One of the few cases I did see, however, disturbed me immensely - so much so that I recalled it on Thursday simply because it was Thanksgiving.  Around three in the morning I picked up a routine-looking patient - a sixty-eight year old woman complaining of pain on urination.  Why she had waited until the early hours of the morning after Thanksgiving to come to the ED was initially mysterious, but after I talked to her for a few minutes and found out that she was chronically homeless, it seemed a little less so.

She had been living for several months in a pedestrian subway in a neighborhood I had actually lived in many years before.  This fact was somewhat humbling to me since during my tenure there I had regarded the subway with fear and opprobium as a certain locus of opportunistic robbery, preferring after dark to sprint across an eight-lane arterial road rather than use it.  She was also floridly schizophrenic and not taking any antipsychotic medications.  She talked to me in some detail about various, mainly intangible problems, a notable exception being the "rats that bite your genitals" (which I know were fictional because I performed a physical examination commensurate to her presenting complaint - I have seen people caught out badly before by assuming that homeless schizophrenics' claims about their bodily afflictions are delusional).

She had, I was fairly certain, a simple genitourinary infection which can be treated with a single large dose of antibiotics, so after I ordered this there was really no reason for her to stay in the ED.  However, when I returned after the nurse had administered her medication to check on her, I found her warmly wrapped in hospital blankets and sleeping soundly.  All of the other beds in her three-bed bay were empty, and if the look on her face was not one of perfect beatitude, at least it was not the look of someone battling with hallucinatory genital-biting rodents. 

So I did what I thought was the obvious thing, and left.  I figured she could stay there until the social worker showed up in the morning and could find her a shelter, or until the bed was needed for a more acute case, whichever came first.  None of this was disturbing, except in the quotidian sense that all manifestations of America's grotesque disparities in health care and radically inadequate mental health infrastructure are disturbing.  What made me remember it was what happened a few minutes later.

As I said, I thought that letting her sleep was an obvious thing to do until her nurse stopped me in the hallway and, with a patronizing look suggesting that I was not benefiting much from my training, said "Hey, that lady in seventeen - does she really need to be here?"

"Well, no," I said, "except that the regular social worker doesn't come in until seven, so I thought we'd just let her sleep until then - as long as we don't need the bed."

"Then why can't she wait in the lobby?" she answered.

"Aaaah," I said, somewhat flabbergasted, "I guess she could.  It's just that, I don't know about you, but I don't feel very good about waking an old homeless lady and kicking her out of the first bed she's slept in in months on Thanksgiving night so that she can go sit in a plastic chair in the waiting room."

"Well, just so you know," she said, "we try to move people through as soon as they've received their medical treatment."  And, after shooting me a malignant look, she stalked away.

What the nurse in this story did wasn't motivated by personal cruelty - it emerged from an extremely common defensive strategy adopted by safety-net health care workers all over the country, which consists in trying to insulate yourself from the monumental inequality and social evil to which you are exposed in horrifying detail by retreating into a narrowly defined professional purview, and denying the legitimacy of anything that falls outside it.  This self-imposed limitation of your field of vision allows you to avoid the unpleasant experience of witnessing things like this and of thinking about your own implication in the system that produces them.  For the nurse, fretting about ED throughput is a way of fortifying her psychic well-being - of avoiding constant anger and depression.  Cruelty is an unfortunate byproduct of self-preservation.


I have seen a number of instances of this kind of institutional, bureaucratic cruelty in the intervening year, some of which I've written about in previous posts, but this one stands out for its concise demonstration of a principle which we should all be thinking about as the frustrating and compromised project of health care reform shambles onward into the new year: the homeless schizophrenics aren't the only people who are brutalized by the current health care "system."  The people who run it, the emergency room nurses, the doctors, and the clerical staff, (and I think I implicated myself rather comprehensively in this group in my last entry) are also belittled and perverted by it.  They're driven to adopt attitudes, simply to safeguard the person they want to be for their family, for their friends, for everyone in the shiny functional world of their stable, employed, housed lives outside the county hospital, which distort who they are in the hospital in frightening ways and lead them to do things like suggest that there's something obviously stupid about letting an old homeless lady sleep in a bed that nobody else is using.

It will be interesting to see how (or if) whatever reform is ultimately passed changes things in ways that allow people at the coal-face of health care in underserved areas to be more like the people they almost uniformly want to be, and less like the people they end up settling for being.