Friday, June 15, 2007

The Poor Get Poorer

I've written here before about my great respect and affection for the security guards at the hospital, and about the invaluable role they play in calming and caring for psych patients (including attempted suicides, addicts and alcoholics, and a number of homeless frequent flyers).

During my shift this week, one of the guards -- who was watching two homeless alcoholics -- told me that there's been a change of policy. Security will still show up to evaluate each of these patients, and will put them in restraints if there seems to be any danger of violence, but they'll no longer sit with them. They'll evaluate each patient and then leave.

My heart sank when I heard this. We used to have social workers in the ED, who were a valuable resource for these patients. We lost the social workers during a budget crunch, much to the distress of the medical staff. With the social workers gone, the security guards became even more important to the psych patients, and now their role is being minimized. This means that, during the many many hours these patients usually have to wait for an outside psych eval, or to be transferred to another facility, the only people they'll have contact with will be harried medical staff or the occasional chaplain (the department doesn't, unfortunately, have round-the-clock spiritual-care coverage).

And many of the medical staff are decidedly unsympathetic to these patients, especially the indigent ones. Remember the nurse who loudly told the entire department that a particular frequent flyer was a worthless human being who deserved to die? The bad news from the security guard was all the more upsetting because I'd just gotten an earful from that same nurse about homeless people who "abuse the system" and tie up beds needed by more deserving patients.

I know a lot of ED staff feel this way, and I know that homeless patients can be hard to deal with (so can homed patients, of course). But the homeless, however challenging some of them may be, haven't created a situation where emergency departments are often the only places they can get any care at all. "They just come here for shelter and food," the nurse told me, as if shelter and food aren't pressing survival needs in a city where homeless shelters are all too often overflowing, or won't accept walk-ins without a referral from a hospital or social-service agency.

Another provider standing nearby was similarly scornful. The nurse isn't alone.

The security guard told me that he gets mad at some of these patients, too (and so do I, when they're rude to me or other staff), but he also acknowledged that he's really mad at the system. I once heard a doctor make the same concession. I don't think the nurse is there yet. When I mentioned the new policy, the nurse said, "Well, it's about time. Now maybe some of those patients will just leave."

Just leave? "Those patients" include attempted suicides, here in the state which consistently has one of the highest suicide rates in the country, along with dismal mental-health services. (Those services are pretty thin even if you have insurance, let alone if you don't; a comfortably middle-class friend of mine whose son needed to be hospitalized for psych issues wound up sending him to Texas.) We want suicidal people just walking out of the hospital?

I have to assume that the security staff is as overworked as everyone else, and I thought they might be happy about having hours of their time freed for other duties. But the two guards I spoke to about the change in policy seemed genuinely upset. They feel they provide a valuble service to these patients, and they enjoy this part of the job. Gary and I, when we talked about this, wondered how many other opportunities the guards have for supportive, non-adversarial contact with patients, since they're otherwise summoned only when someone's become obstreperous.

I keep reminding myself about the many members of the ED staff who've managed to stay compassionate: The nurse who thanked me profusely when I found a shelter bed for an alcoholic, because her father's alcoholic and she knows how tough that illness is. The nurse a few weeks ago who thanked me for finding some clean clothing for a homeless man, and who ordered a meal tray for him even though he was being discharged -- and then let him carry the tray into the waiting room and eat his dinner there, since another patient needed his bed. The nurse who sympathized with one of our schizophrenic patients, and agreed with me that it must take unimaginable strength to keep coping with the worst symptoms of that illness.

And, of course, the security guards.

My conversation with the first guard last night started because he'd heard me offering pastoral care to one of the homeless alcoholics. The patient politely declined, but thanked me for my visit. When I left the room, the guard said, "I didn't realize you were a volunteer chaplain. That's a really important job." And then he launched into a fluent, impassioned monologue about how important it is to treat homeless people like people. He told me about some of the ways he's helped them at the hospital; he told me about teaching his girlfriend's son to be compassionate by striking up conversations with homeless people in the park. He told me about a friend of his father's, hit by a car in a large city and thrown into a doorway, who lay there for two days because passersby assumed that he was homeless and wouldn't look at him, much less help him. (This unfortunate soul wound up losing his leg, which could have been saved had he received medical care more promptly.) He gave me an energetic little pep talk about the value of my work, and I returned the favor.

Later during the shift, I had a long talk with a patient who's been a corrections nurse for decades, and who waxed equally eloquent about her frustration with how many prison programs have been cut. She's helped a lot of inmates turn around, and it frightens her that the resources to give them useful job skills -- the skills that will allow them to make it when they get out -- keep disappearing. Talking to her was more proof, if I needed it, that it's possible to work in a very hard environment without becoming completely cynical and embittered.

I suspect there's no way for me to talk to the angry nurse about this; that nurse, I'm pretty sure, now considers me almost as contemptible as the down-and-out patients, simply because I've tried to advocate for them. In different contexts, I like the nurse, who's gone to great efforts to help other patients. I'm praying to maintain my own compassion towards this person, and towards other staff who take their frustration out on patients.

In the meantime, it scares me that we'll be seeing so much less of the security guards. Some patients really are dangerous, and can become dangerous in unpredictable ways and at unpredictable times. I always feel safer when the guards are there, and I'm sure the medical staff does too.

But it also scares me because the guards protect the most marginalized and vulnerable patients. Without the guards there, I worry that burned-out staff will feel fewer compunctions about telling those patients that they're worthless, that they deserve to die, and I'm scared that the patients -- most of whom feel horrible about themselves anyway -- will believe it.


  1. Me, too, Susan.

    Except that it's happening to me personally. Dehumanization seems to be not only tolerated by nurses, but is encouraged.

    I've enjoyed your blog immensely. All good things to you-

  2. Anonymous1:54 PM

    When I encounter people like that nurse who considers homeless addicts contemptible, I try to remember that they're operating from a place of fear. That helps me to have some compassion for them. But then, in the moment, that ain't always easy!

    Jeff P.

  3. Too bad, too bad. One of the many ways in which our health-care "system" is broken.

  4. huh. There's something really ironic in calling someone a "provider" when all they do is hope the patient goes away.

    The cynical side of myself says that all you'd really have to do is get a local paper to run an article with the headline "Security Cut in Local Hospital: Are Staff and Patients in Danger?" and you'd have your guards back asap.

    In the broken system I'm striving so hard to enter, people like you give me hope. :) Thanks.

  5. Alexis -- You're welcome! Two points: 1) Security would of course still respond to any emergency (although presumably not as quickly as if they'd been there all along), and 2) I know of at least one other hospital nearby that never did have security guards watching psych patients, that just slapped them all into restraints automatically (which brings its own issues and problems, of course). So I suspect that there's a pretty wide range of accepted practice on this.

  6. Anonymous2:52 PM

    The bean counter's creed when it comes to chronic affliction is 'Dulce et decorum est, pro patria mori', and we all know how it sometimes feels as though the bean counters are in charge of everything.

    Holistic caring, now there's a dream worth having.


  7. Wow first off I say report that nurse! I do not care how harried she is or frustrated for that matter, she can go home at the end of her shift and calm down. As a nurse, the first thing we are taught is not to judge our pts. Yes, sometimes this can be challenging but it is not our place to be their judge and, like you said, the pt probably feels worthless enough. I am mad just thinking about this woman! I am an advocate for the homeless. I worked for a while at a homeless clinic here in town at the Salvation Army. I cannot tell you how many sad stories I have heard and seen. I do not, for one minute,think that any of these people grow up thinking I am going to grow up to ba an alcoholic or shiftlees on the streets. There but for the grace of God go I is my motto. I am a home health nurse and so I am on the streets a lot myself. I carry clean socks in my car and when I see a homeless person on the street corner with their signs I always offer them the socks and if they will let me I will pull over and wash those same feet. A lot of them have trench foot because they live in those shose 24/7.Some of them will let me and some not so much. They are frightened or mentally unstable. I "doctor " the ones I can and pray for them all. What so ever you do to the least of my brothers that you do unto me. I wonder if that same nurse would look at Christ and deem him a worthless person who deserves to die? Seems to me like she already did! God bless you and keep up the good work. Obstreperous... I learn something new every day!


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