Student Reflection: Ischemic Impasse

Starting in a dusty parking lot across the street from Foundation Coffee, we trek down Franklin Avenue atop ancient cobblestone, passing the historic Tampa theatre, eventually reaching Gaslight Park. Each street run may follow the same route, but never the same course. Along the way, our troop of well-intended students and providers will pause at every opportunity to offer what we can to provide relief to Tampa’s homeless. This may take the form of clothing, cleaning a wound, or simply conversing. Our collective knowledge is perhaps most valuable when we can identify issues that go beyond our scope of care.

I first saw Douglas about a month ago, half a block off our normal path, his long, wispy, white hair engaging the windy night. An aged gentleman and a veteran of the street, his body had borne the full brunt of living with no place to call home. Tattered clothes, excoriated forearms, sun-damaged, wrinkled; he was stationed with his hands on his knees, apparently in discomfort, speaking in short breath. After disclosing my intent, he stated “my chest feels tight and it hurts.” He’d had two heart attacks that felt similar and was not currently taking any medication to manage his health. We promptly reached out to emergency medical services and pulled four 81 mg aspirin tablets from the supply bag for him to crush between the few teeth he had. The ambulance arrived and whisked Doug and his humble living supplies off to Tampa General Hospital (TGH).

After a few Street Runs you start to become familiar with the unsheltered inhabitants of the city. Though they may have no roof and few worldly possessions, by staying in the same area they develop a neighborhood, a sense of community, and a more stable living.

On the next street run, two weeks later, we ran into Douglas again. I was elated to see he’d made it out of the hospital and, though I wish his circumstances were different, he’d resumed normal life. I greeted him as he reclined on a bench not far from where we first met, and apparently in better spirits: “How are you today?” His face straightened a bit.

“I’ve got this tight chest pain and would like to go to the hospital, but don’t have a phone.”

I didn’t expect a moral dilemma today… He doesn’t look like he’s having a heart attack, but he wants medical attention. He was describing what sounds like stable angina: chest tightness triggered by walking short distances and relieved by resting after about twenty minutes. His medical history certainly warranted a lower threshold for concern. This man had every right to access emergency health services, and if he had the means, maybe he would have reached out by now. At the same time, these are precious city resources. If I called an ambulance every two weeks for the same person experiencing what I know are non-emergent symptoms, he may eventually be treated as a nuisance patient.

USF’s relationship with TGH fortunately grants mobile access to patient records. With his permission, we delved into his chart. He’d been to TGH twice more in the last two weeks. Each time he received the ‘chest pain workup.’ Negative heart attack markers in his bloodwork and unchanged EKGs were shown at every visit. IV fluids were given followed by a hasty discharge. Despite demonstrating hypertension each time, he was never given blood pressure medication. Despite evidence and history of coronary artery disease, he was discharged without prescriptions for nitroglycerin, statins, or even daily aspirin. Standard of care management that every single physician is taught in medical school was not being employed.

With a more thorough understanding of the state of Doug’s health, we explained to him the nature of his pain in layman’s terms. “You need a few medications on a daily basis to help you live longer and experience fewer of these symptoms.” Through his stained, scraggly beard, he expressed understanding, counterposing only with the difficulty of acquiring and affording therapy. After handing him a flyer with explicit detail of the clinic we offer on Saturdays to address those concerns we asked once more: “Do you still want to go to the hospital?” He nodded yes, following with a declaration of intent to visit our clinic when it was offered next week. This is where I know we could change his course.

The same firefighters we interacted with on the last Street Run arrived quickly and jokingly remarked on the deja-vu. They evaluated our patient and shortly after, the same ambulance crew arrived. “We know you normally go to TGH, but their emergency department is at capacity. We’re going to take you to St. Joseph’s if that’s ok.” Douglas grabbed his bags once more for yet another trip to another ED.

There is no doubt in my mind he will continue to return to the Emergency Department time after time only to be discharged shortly after, all the while, costing you, the reader, and myself thousands of dollars with each visit. The dispatched fire-department crew, the ambulance for transport, the hospital bed and evaluation – all valuable and in high demand. The cost of chronic homelessness to the taxpayer becomes astronomical as this cycle continues. The 2014 Florida Homelessness Report followed 107 chronically homeless individuals in Osceola County for one year. Emergency Room visits and hospitalization expenses for this cohort climbed above $2,160,000 that year, supporting the strong argument for maintaining the health of our homeless. As healthcare providers, we must understand the importance of preventative medicine regardless of situation or specialty. This man is tracking toward premature mortality, a trend of homelessness demonstrated across the country with remarkable consistency (Montgomery et al., 2016).

With luck, seeing Douglas at our clinic and implementing the standard of care for his comorbidities will increase his quality of life and capacity to live. Such endeavors benefit a population in dire need and, in a short span of time, the society they belong to.

References

1. Montgomery, A., Szymkowiak, D., Marcus, J., Howard, P. and Culhane, D. (2016). Homelessness, Unsheltered Status, and Risk Factors for Mortality. Public Health Reports, 131(6), pp.765-772.

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Fahd Rahmouni Idrissi is a third year medical student at USF Morsani College of Medicine and Vice President of TBSM.

As reflection imbues work with meaning, provides deeper insight, and promotes complex learning, TBSM volunteers are invited to write about their personal experiences and the process of service learning with TBSM every month.