An Exercise in Futility

By: Conor Holton-Burke

“I’m a dead man walking.” Those were his first words. He said it airily, as his cheeks climbed his deeply creased face in a crooked smile that caused his unkempt beard to obscure his eyes: the juxtaposition of jolly and macabre characteristic of those experiencing homelessness. After spending some time with him, I had to agree with his initial assessment. If I were being pedantic about things, I would argue that he wasn’t actually “walking.”

He was in a wheelchair, huddled under a grimy collection of jackets and blankets, which protected him from the uncharacteristically chilly day. He had uncontrolled diabetes, and knew that he was supposed to be taking insulin twice a day, but didn’t know how much or what type. He had recently left an emergency room, where they had helpfully given him a paper subscription for his insulin and patient information pamphlets. They didn’t ask whether or not he knew how to read (he couldn’t), if he knew where to fill it (he didn’t), how he would get to a pharmacy (he couldn’t), or if he had a refrigerator to store the insulin in (I’ll let you guess). Consequently, he hadn’t taken any diabetes medication of any kind, and he was feeling nauseous.

He also had an open wound in his belly that was draining a light brown fluid that smelled like a rotten egg in a dirty sock. He said that a hernia had been repaired several months ago, but the wound had never healed. The fluid wasn’t stool, and the wound was not actively infected, but it was a recipe for disaster. Also, his right scrotum was the size of volleyball. Also, his feet were the color of beets, and he had open wounds along the dorsum of both dripping a fetid, creamy fluid into his yellow, crusted socks. To top it all off, he had suffered a stroke several years back, which had cost him the ability to read and left him completely incapable of navigating the city he lived in.

We would have sent him to the emergency room if he hadn’t been wearing the wristband from the emergency room he had just left. Despite having a blood glucose in the 300’s and the aforementioned ailments, his discharge paperwork said that he “did not have an emergency medical condition,” and they discharged him to The Beacon.

With a healthy amount of skepticism, I checked the Harris County health record only to find to my horror that his story was largely true. A few days prior, he had been to Ben Taub where they had e-prescribed his medicines (because Ben Taub no longer has an in-house pharmacy), scheduled a follow-up appointment in South Houston (that he had no hope of ever making it to because he could not read the directions he was given), and placed him in a personal care home (which he refused to go to). The only thing we could do was try to reschedule his primary care appointment to the only place he knew how to get to in the whole city: Ben Taub. We weren’t even able to do that. Failing to help him in any way, I gave him a water bottle, put a clean pair of socks on his weeping feet, and told him to go to the Ben Taub Emergency Center when he started to feel worse. He was obscenely grateful for these small tokens, but hearing his litany of unsolvable problems left me hollow knowing that this cycle would likely continue until he died.

To the more seasoned clinicians in the audience, please know that I am not hopelessly idealistic. Healthcare professionals can only accomplish so much without some manner of personal responsibility. I know that by refusing to go to the proffered personal care home, his “dead man walking” pronouncement became more of a self-fulfilling prophecy than a victim-of-circumstance situation. I only wish to point out the many inadequacies in our heath care system. Without an in-house pharmacy, illiterate patients are virtually guaranteed not to receive their medications or take them properly.  If we schedule primary care appointments outside of the city, we need more accessible transportation options, especially for wheelchair-bound patients. We also need to reassess how we treat patients with disabling illness. For many, personal care homes and skilled nursing facilities are not tolerable. It’s tempting to tell this patients not to look a gift horse in the mouth, but if we don’t address our patients’ needs we are dooming patients like this one to visiting the ER multiple times a week without receiving any medical or social treatment of value.

Conor Holton-Burke is a fourth year medical student at Baylor College of Medicine. He is an active volunteer for HOMES, serving both in clinic and street outreach. During his third year, he completed the HOMES Pathway for Baylor's LACE program.