Monday, May 24, 2010

To Feed Or Not To Feed

I walked into Room 22 to find a very interesting patient who presented to our ER with complaints of abdominal pain and associated nausea and vomiting.

The patient sat on her cot with her pant legs rolled up above her knees, refusing, according to her nurse, Gwen, to put on a treatment gown. Her left leg hung in the air, her ankle crossed over the knee of her right leg. Her feet were bare and dirty. Nestled in the crook of her left hip, resting on the cot, was a worn bible, opened to the first page of The Book of Genesis. As Gwen was trying to obtain a better history, the patient was obviously ignoring her, giving all of her attention to the her bible.

Or so I thought. I walked into the room and introduced myself to this patient. She briefly flit her eyes up at me several times. Finally, after gaining her approval, she steadied her gaze on me and extended her hand. We shook. Gwen, meanwhile, seemed to have gotten an even colder-shoulder than before, as the patient turned her back on her to give me her undivided attention.

With her gaze on me, I absorbed this patient's features. She had dirty-blond hair pulled away from her face. Long, thready, frazzled dreadlocks started at the crown of her head and were gathered behind in a bulky ponytail. Her eyes were piercing blue and, quite honestly, unsettling. High cheekbones, clear skin smudged with some dirt, and thin narrow lips accented her prominent nose. Her hemp clothes were worn and faded, tattered almost, and, like her skin and bare feet, smudged with dirt.

She was in her early twenties.

"Hello, Rose," I said with a warm smile, "what brought you to our ER today?"

Her voice was husky yet quiet. "I ate some fish yesterday and I think it was rotten." She went on to explain that she, at the time, wondered if the fish was "not good" because it had "a funny, pink color to it, like salmon. And" she confidently added, "I know my fish--it wasn't salmon."

"Where did you eat this fish?" I asked her. She blatantly ignored my question, which made me wonder if it was from a clean site or a garbage can.

She continued, however, to explain that since eating the fish, she had vomited three times later that evening and once this morning, prior to coming to our ER. "I feel better now, though," she said. She hesitated before continuing. "I'm feeling well enough for a cup of coffee and a sandwich, even."

And there we go--the main reason why Rose was in our ER. She was hungry.

It turned out that she had already asked Gwen for some food and coffee and Gwen had put her on hold. "Rose," Gwen had explained, "we need the doctor to see you and get some of your blood results back before we can give you anything to eat." That explained the snubbing of Gwen. I had to smile, since Gwen was an extremely compassionate, cognizant nurse.

"Rose," I said, looking her in the eyes, "is this the real reason you came to our ER? Are you hungry?"

Rose stared at me as I visualized the cog wheels in her brain churning. Finally, she spoke. "Um," she started, "I came here because I ate some bad fish. But now I feel better. So yeah, I guess so. I was hoping, I guess, that you guys would be able to give me something to eat." As she spoke, she held my gaze. I appreciated her efforts at honesty.

Gwen looked at me with her knowing smile. I looked back to Rose. "Rose," I said, "I need to perform an exam and, since the triage nurse ordered some blood work, I need to review your results and make sure they are all good before we can let you eat. You understand this, right?"

Rose nodded her approval. With Gwen at bedside, I performed a thorough exam of Rose. Everything checked out well. Specifically, she had no abdominal pain on exam. I walked out of Rose's room and reviewed her stable vital signs and her stable blood work on my computer station.

As far as I was concerned, we could now feed Rose.

Which presents the dilemma we sometimes face in the ER. Frequently, we get unfortunate patients that present for reasons other than emergent medical care. It might be a drunk, homeless person, refused for the night by the homeless shelter for his alcohol abuse, who is looking for a place to sleep. It could be a patient who is looking for free prescription vouchers to get his medications renewed. And, in Rose's case, it could be a person simply looking for a meal, a cup of coffee, a warm blanket, or some companionship.

As far as I am concerned, we should extend ourselves, as long as it doesn't take away from providing emergency care to those in dire need. And, as long as our efforts are appreciated. Is a bed free? Go ahead and lie down for a short while. You're hungry? Let's see if we have any pudding or turkey sandwiches for you. Your cold? Here is an extra blanket for you from our trauma blanket warmer. Free vouchers? Well, I see those cigarettes and iPhone poking from your pocket, so we're not going to be able to help you with that tonight. Sorry, but I can only go so far.

With these acts of kindnesses, though, I understand the flip of this coin. You set yourself, your ER, and your staff up for repeat visits by these patients who come to expect these kindnesses every time. And, as a result, they keep coming back and coming back and coming back. Sometimes clogging the system. Eventually, these kind acts are no longer appreciated but, rather, demanded. We've all seen this happen. And it's at this moment when our thought process changes.

With Rose, she had only been to our ER once before so, after Gwen and I agreed, she received a full meal, some warm coffee, some foot slip-ons, and a social service consult prior to being discharged. She was gracious for everything, which helps the cause. And it was our pleasure, really.

However, there are repeat offenders whose visits to our ER number in the fifties and hundreds. Seriously. And, unfortunately, these handfuls of patients are the ones who can ruin it for the others.

The ER presents many moments of internal struggle where, as an individual working there, you have to review and examine your moral fiber and essence. This is one of those struggles for me. I wish we could accommodate every single person's needs, but that is unrealistic. So, I'll just continue to provide on an individual basis. And, hopefully, these kind acts will be appreciated and not abused and demanded.

To feed or not to feed...that is the question.

Happy Monday. I'm eager to hear your thoughts on this post... As always, big thanks for reading. Next post will be Wednesday, May 26th. See you then...


kristi said...

I would have fed her too. My husband went a few months ago because he had done something to hsi back. He was basically treated like a junkie....which I didn't appreciate! But he had surgery at another hospital the following week for a herniated disk.

James and Elizabeth said...

Great post. This is one of the reasons I went into Emergency Medicine. I love to help those that have been marginalized and dismissed by others. But I agree with your internal debate over that you set yourself up to some degree by helping. Thanks for your thoughts.

Anonymous said...

I know this dilemma well.

We once gave a mentally-ill, addicted, homeless man breakfast and dinner, as long as he showed up for his IV therapy each morning (which was an IM of ceftriaxone daily to clear up a nasty cellulitis). The deal was to come in before noon each day, get his shot, and we would hold a tray for him for breakfast, and later he would show up, get his dressing changed, and we'd give him a bag-lunch on his way out. This man had a bad reputation in our department, so part of the deal was he had to behave. It worked out well...his cellulitis cleared up, and his health improved a little bit. SW met up with him several times, got him hooked up with some resources. I haven't seen him in a while, so who knows, right?

That being said, a similar arrangement with another individual had the opposite effect, and we've been dealing with the repercussions ever since. Without the meal, warm bed etc, he becomes angry, violent, and usually ends up with us calling the police because he starts throwing things around the waiting room.

So I don't know what the answer is...the compassionate part of me wants to give to people who have so little, and whose lives are, quite frankly, miserable. The other part is concerned with safety and self-preservation. It's a balancing act most days, I'm sure.

soulful sepulcher said...

I think you did the right thing giving her food. I agree there are frequent flyers, and then to make the call on giving her the food was one you had to do based on experience.

I spent quite a lot of time a few years ago interviewing homeless women and men in a downtown area, under a bridge where a homeless man who had died in jail---spent his days and had planted a garden of iris and wonderful flowers.

There were 2 sides of this under the bridge area. One side (devided by a street)is where the filth and buckets of feces and people honestly and openly asking for drugs, etc.

The side where the garden was, were people that were also homeless, but did not ask for anything except water to drink.

I pulled my car into the area under the bridge and got out to give a woman water, and we started talking, which led to many months of my visits there.

They changed my life. I learned hope came in so many forms, and sometimes people just need someone to be kind and listen, in their dire circumstances.

I soon began planting flowers and bulbs there, as there was an article about the garden and the man's death, and no one to tend it.

The columnist ended up re-writing his article, and he too, planted flowers and daffodil bulbs there as a result, we called it "The garden of hope".

One of the times, later during a cold winter day,near Christmas time I did a drive-by to see if anyone needed water. I found police and firemen and one homeless man on the ground refusing to get up. Surrounded by his belongings in bags and a bike, I aked him what his name was.

He told me it was Joseph.

I asked the officers where everyone else was, and they told me it was a "sweep". Joseph, they told me was refusing to get up and if he didn't they were going to place all of his things in dumpster bins.

I approached Joseph again, and explained what was about to happen. I asked him if he was in pain, or any reason he could not get up and carry his things and walk away. He told me his back was in pain.

I told the police to call an ambulance, he needed medical care. They did. When the crew arrived, it was very ironically, a crew that had transported my daughter during a mental health crisis to the hospital.

We hugged---and I told them this was Joseph, and he needs to be treated with dignity and respect, and they told me he could take ONE hefty bag of belongings.

I approached Joseph, and asked him to point to the items he wanted the most and I would bag them for him. The firemen promised to tag and hold his bike at the firehouse for him.

As I stood there, watching the ambulance drive away to take Joseph to the ER, I saw many facets of humanity in action, that we are all connected in some way.

This makes me glad, Dr. Jim, to know that you and your staff look after people, like Joseph.

Kate said...

I worked for the church as a youth director for 10 years and we'd have many, many discussions on this same topic. The church is also a haven for people seeking food, rest, and companionship.

After one heated staff meeting where people were throwing out all kinds of all or nothing ideas, something popped into my head and well, it made the most sense at the time, as we were talking about "THOSE PEOPLE (I hate that phrase) that get government money and spend it all on cigarettes and alcohol." I said, "But they're still hungry." And that's that. And I still stand by that today. No matter what they did with what they were given before, they are still hungry.

soulful sepulcher said...

*This post inspired me to write one and link this, but my comment I left here is missing...? I had copied it on my blog, though. Maybe a blogger glitch...

Lisa said...

At my church's food pantry, we feed whomever walks in the door. We know they smoke and drink, but that's not for us to judge. Sometime's a local nurse's association gives us vouchers for $4 perscriptions at Kroger or Walmart that we can pass out to people in need of getting their perscriptions filled. If they need clothes or shoes we let them pick things out from our closet. We fix cars and we pay utilities, and we will even let people wash up in our bathrooms. We know and accept that there are those who are taking advantage, but we have decided not to care so that we can reach those who truly need us. This is what our purpose is, this is what we do, but I can see that it could be a problem in an emergency room setting. I glad that you have made the decision to examine the need of people before just turning them away.

The Hopeful Elephant said...

It's the humble, young ones we can reach out to---and hopefully help.

There was never any bad fish. ;)

Katie Axelson said...

My gut reaction was feed, without a doubt, feed. Definitely for a first time visitor and maybe less with each visit but don't punish those in need because of the selfishness of others. However, as I mulled over it a bit longer I realized this is a question being raised all over the world. To feed or not to feed? THAT is the question.

This past March I spend a morning working at the food pantry/ soup kitchen associated with my church. I'd never been there for that even before and while I was a spare set of hands my primary role was an unofficial interpreter. I didn't know the rules; I followed orders. The worker I was translating for told a woman it was ok, we could feed her that day, but in the future she had to go to a different site because she lived out of our district. Translating, it was my mouth that had to say we'll feed you today but we can't do it again. Those words were hard to say because I didn't (and to an extent still don't) understand the rules. I then took great pride in fetching a bag of food for this woman and her family. Not ten minutes later a different woman was sent away empty handed because it was her second visit to this site and she lived outside of the district.

I stick with my first answer of saying feed, but I also realize that in today's society a line must be drawn somewhere. But no matter where you put it, it's not an easy line to draw.

Great question!
<>< Katie

tracy said...

Kindness first. i used to work at Cathedral Outreach, where we helped people with sack lunches refferals, gasoline vouchers and sometimes store vouchers...i loved the work and miss it so much. You never knew who would show up at the door...The Bishop...or a person inpersonating a priest! :) (It was in another state....time to find something similar!).
Thank you for the reminder, Dr. Jim.

Mark p.s.2 said...

As a citizen of the country, the homeless deserve a few chances to get back to "normal". I say feed the homeless , yes. A full stomach makes a person feel less angry person as well. I assume the anger comes from pain. You might reason/communicate with someone who is not in pain.

Karen said...

I can't imagine being in these circumstances... having to fake an illness in order to have food. I would rather make bologna and cheese sandwiches at home to bring into work than turn someone away hungry.

J-Quell'n said...

It's a double edged sword...meh. I want to feed and cloth and love them all...unfortunately, without drawing the line somewhere, good deeds get exploited. No easy answer.

Cal said...

Seeing someone go hungry is not pleasant... I think you did the right thing, although I have a hard time imagining all you guys must witness in the ER, and all the questions that must go through your mind. All these people have a story to tell, and one must wonder what that entails.

CharityVL said...

This was a most impressive post. I kept waiting to see if I would disagree with you, but I did not, on any points. You covered this whole issue so well, with compassion and also realism. I have a feeling you would know just when and where to draw the line.

Anonymous said...

You did the right thing, Dr. Jim, both in feeding the hungry woman and in making your decision based on her particular circumstances, rather than lumping her in with the many other people who come to ERs looking for drugs, food, a bed ... Each one, as a human being, deserves that consideration.

It's hard for me to imagine living without a home, without money, without food, and without hope for my circumstances to change. I'm soft-hearted; I'm afraid I'd be a terribly pushover in your situation. And yet I can also understand the frustration that medical personnel at ERs feel when they're lied to so often and taken advantage of. I guess there's no "easy" answer to this problem, but I can only respect your compassion. And I'm very glad that this homeless woman had her stomach filled.

Anonymous said...

I don't know, I guess I have to be the dissenter. If this woman didn't have an actual medical problem and all she wanted was a sandwich, that was an awfully expensive sandwich for us taxpayers, given that she received a lot of expensive and presumably unnecessary medical care along with it. I'm watching my medical insurance premiums go up like crazy. Am I paying, in part, for unneeded medical care for people who really just want sandwiches?

MLee said...

Well I must say I am a sucker. I feed. I normally sneak for out to them, or so that they think that I sneaked it because if they perceive that I am not allowed to give it, which we are not, then they will not expect it and come in every meal time. It sounds horrible but if we feed everyone or they think it is a reason to go to the ed then we are over whelmed and do not have cots for the clients that need them foe medical conditions.

coulrophobic agnostic said...

What an interesting dilemma. And of course, on one hand, it's not the ER's job to do so - on the other hand, can it ever morally right to send someone away when you can give them what they need, without taking care away from others who need your intended services?

I mean, for me it's a no brainer at least on paper, but I'm curious - is it "allowed" to do such things? In other words, if a higher-up knew about it, would the helpful party be reprimanded? Especially if the person was a regular who became difficult, as one of your commenters described.

And Kate also brings up an interesting point - what about people who spend their money on other things (like the person with cell phone and cigarettes but no money for cab fare) and thus can't afford to eat? Yes, they're still hungry, but it's a direct result of their priorities and decisions. Should that have an effect on what's done?

Is there a line, should there be one, where is it? Etc.

So many things to think about that, unfortunately, too many people would rather face with a shrug and a "not my problem."

Have Myelin? said...

...and I'm threatening to go to the ER so I can get a prescription for Copaxone since I can't find a neurologist that accepts Medicaid! I'm out of refills and now injecting every other day instead of daily like I'm supposed to.

I honestly don't know what I think of this. I can't find a neurologist, a GI doctor nor a urologist.

I can find a food bank for help if need be.

I don't know what the answer is... but this is a great post.

911RN said...

I feed! Always, unquestionably and without judgement. As Kate said...they are hungry!Regardless, of how many times they have been to the ER.I feed.

We have a relatively, low population base with few homeless so, the "food seekers" are few in numbers. WAAY lower than the 'drug seekers'- for sure! However, many folks are living marginally and I always choose to feed.

I have even given box lunches "to go" if they are thin or appear malnorished. Is it right for folks to use the ER as a soup kitchen/food pantry? No, it is not. But, the drunks go to sleep after you feed them and the angry- they quiet down.

It is just as medicinal as any pill. It's an effective, non pharmacological treatment. Call hunger the symptom or illness. Food is the treatment.It's compassionate, the morally right thing to do and dirt cheap compared to the rest of what we do in the ER.

I have never felt the gnaw of true, hunger pains and I could not sleep, at night, if I ignored another's plea to quiet their own. To be hungry enough to go to an ER-for food, has a desperate ring to it, all by itself. They are attempting to meet a basic need and food is necessary for "health." That's our business- good, bad or indifferent.

I understand the debate about those that abuse but it is a somewhat empty argument. They are hungry. For whatever reason. I can't "fix" their reason, usually. But I can offer them food- it's humane and all I can do. To feed- always...that is the answer.

Great relevant post.

Amber, said...

Definitely would have fed her too, if it didn't keep your attention away from someone who really needed it. Great post.

Anonymous said...

It sounds very manipulative to me.

I have recently relinquished a sociopathic friend who successfully disguised herself as such for two years. You couldn't talk her out of being the way she is. It's the same thing with this woman, and the other 50-100 returnees too.

I wonder if, given their history of probably childhood abuse and neglect, if they just yearn for human contact as well, in the form of touch, communication, caregiving?

In this sense, it is more valid to consider feeding, but not in a hospital emerg. Unfortunately shelters are not always the best option either. What is the solution?

Anonymous said...

As usual a wonderful, thought provoking post. Several years ago my job dried up and along with it went my health insurance and my dignity. I sunk into a deep depression which didn't help things. Somehow I managed to get impetigo on my face and the OTC antibiotics weren't working. Out of money and without health insurance, and with the infection on my face getting larger and larger I didn't know what to do. I swallowed my pride and went to a church sponsored clinic for the indigent. I was beyond embarrassed. I will never forget how kind everyone was to me, from the volunteer receptionist to the CNA who took my vitals, to the volunteer physician.

The physician was retired, I think, except for her volunteer work with this clinic. She had been a physician for many years and had likely seen and heard pretty much everything. But, somehow she wasn't jaded by her experiences. She wasn't just interested in my infection she genuinely wanted to know about me and how I had ended up in the situation I was in. Still unable to look her in the eye, I began to tell her a bit of my story. She could tell how difficult it was for me to be there. She did so much more than treat my infection that day. She put a salve on my wounded spirit. Just a gentle, kind woman. I will never forget her.

After she handed me the antibiotic ointment, she asked me what I was going to do for dinner that night. I said I would figure it out. She asked when I had last eaten. I could feel my face flush red and I said I was fine even though I had not eaten in about 2 days. Maybe I looked skinny, or maybe she just suspected I didn't have food, but she walked over to her purse and pulled out 2 bills ($40) and handed them to me. Tears started running down my face, and I was stammering that I couldn't accept this, and that I was fine and everything was fine, and I put my hands in my pockets and I wouldn't take it. She said I want you to take this, and I only ask of you two things. One that you'll buy food with it, and two that you'll contact me and let me know how you're doing. She handed me her business card with her contact info on it. As mortifying as it was, I did take the money, and I did buy food with it that day. I don't know why she trusted me, but she did.

Time passed and I went back to school, and I have worked full time for several years since then. I have been lucky enough to be in a position to pay it forward.

The sandwich you offer feeds the physical hunger, but your kindness and the kindness of your nurses and staff help heal the woundedness inside many who cross your path. Thank you for that.

coulrophobic agnostic said...

I don't see how the above poster can say it's manipulation - okay, your friend was a sociopath, that doesn't mean everyone who's hungry and needs a break *once* is. If she starts turning up regularly, maybe.

Smalltown RN said...

Oh doc I hear what you are saying. You want to help them all, but there are limitations. I like how you reference the individual who has the cigarettes and iPod hanging out of their pocket, like you if I saw that I would say sorry if you can afford that you can work at some other way of getting your prescription filled.

It's a hard call. I remember a patient we had in the ICU. She and her partner were homeless. The spent most of their nights in an alcove at the movie theater. She was the most generous person. If she had extra she gave it away. I know this as there were folks who knew this woman before she became homeless. This time she was in need. IT was winter and she got a very bad infection in her lungs it was touch and go for awhile. Anyhow, her partner would come and visit. He was so dishevelled and of course smelt like dried urine. We arranged for our social worker to gather up some warmer clothes for him. He often made his visit to the patient around meal time. As staff we just decided to order an extra meal and provided coffee. It just seemed like the right thing to do.

The patient unfortunately passed away. We never saw her partner in the hospital again. A nurse said she saw him on the street pushing a grocery cart...but he never came back to the hospital looking for food or handouts.

Yes it's a difficult call sometimes, but I think through our years of practise we get to know or can recognize signs of folks who are just there for a free ride.

Great post doc!

tracy said...

Dear Anon #3,
Thank you for sharing your was at once heartbreaking and hopeful and really touched my heart. You write beautifully and i am so happy things are better now.
Bless you.

Katie Axelson said...

I was back at the food pantry again today (since it's Wednesday) and two seperate guys came in almost at the same time. The first handed over his ID and said, "I don't know when I'm allowed to get food again, so I just wanted to check. I really need a toothbrush." Sure enough, he can't get more food until next week. The volunteer helping him paused and then told him to go back and get whatever he needed from the hygiene table (normally they're only allowed one item but he took at least four). The other man (and female friend with him) said they were completely out of food, and again, they couldn't pick up food for another week. All of us volunteers looked at each other and decided the rules were more like guidelines anyway and helped the hungry family. In that awkward moment of my internal pleading, "Please give them food; please give them food" I thought of this post: to feed or not to feed was the question we were asking. The lack of people requesting food today and the surplus of food probably helped the case. We didn't give them a full two bags, but we did provide them with enough to suffice until next week.

I say it again: Feed.

type1medic said...

I love this post. This is one of the reasons I chose to be a medic. We help those who have no other way to receive care and compassion. and with medical care I get the chance to be there in any other way then I will revel at the chance to help. I am glad that rose received the care she needed even with a clean bill of health.

Moose said...

I cannot disagree with your point about cigarettes, but please think twice about an iPhone [or a computer].

Years ago I used to read the 'blog' of a young woman who was homeless after she had a traumatic brain injury. Long story short(er), she had no family and was stuck in the middle of waiting for social services to figure out what to do with her. People used to tell her, "how can you claim you can't afford {whatever} when you have a computer? Sell it!" And she'd say, "This is my link to the world. This is my lifeline."

A year ago I became unemployed and disabled. I didn't become homeless but I came close. The one thing I never let go of was my laptop. It did, in fact, become my lifeline. With no TV, no radio, and a cheap pay-as-you-go cellphone, the laptop was my only way to communicate with people. Like the young woman whose blog I read I'd go to coffeehouses and spend $2 on a cup of coffee so I could sit and use their wireless connection.

So maybe the iPhone is a gift from someone who knows they need to stay in touch. Maybe it isn't. In that case you mentioned, sure, if you can afford cigarettes you can spend the money on something else. But the computer might be a gift to someone as a lifeline.

I guess it's like trying to figure out who is really a seeker and who is really in pain.

Anonymous said...

Tracy, thank you for your kind words. You made my day!

It's amazing how one encounter with a stranger can change a person's entire life. I learned the definition of grace that day. What I received from Dr. S. and her staff was completely undeserved and unearned. Grace.

They blessed me in more ways than they will ever know.

Gia's Spot said...

Dr Jim
for all those unwashed, unwanted, untreatable,uneaten,unhealthy downtrodden people out there, I give you my thanks!
As the sister to a homeless man who has to go to the ER every morning to have his blood levels done, vitamin K shot, and coumadin levels adjusted for blood clots in his leg and lungs, I am truly grateful for the staff who treat him with candor, respect as a human, and even a bit of sympathy! He is only 46 and probably wont see 50 but he cannot seem to fix what is wrong with himself so remains as is. Keep that candle in the window, sir, as it shines on those who need its strength, even for just a moment!
Have a tremendously happy Memorial Day weekend Dr Jim!