How Does a Director of Street Medicine Do Her Job?

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S1: This ad free podcast is part of your Slate Plus membership.

S2: You’re listening to working the show about what people do all day. I’m your host. Jordan Weisman and this week I am continuing my series about people who work in homelessness services. And if you were listening carefully you might have heard a slight linguistic change there compared to the last two weeks. I did not say people who work with the homeless said people who work in homelessness services. There’s a reason for that because that was intentional because I got an email this past week from a listener anymore and she told me that she actually works in social services in New York City and she had a little bit of advice for me. She said please stop saying the homeless. Generally we are really trying to use first person language. No one likes to be defined by their circumstances so please try for people who are experiencing homelessness. It’s temporary fixable problem after all that seemed completely reasonable to me and frankly you know as I’m going along with these shows I’m still learning I’m learning about the field and the people who work in IT and the kind of language they use the things they think about and so I’m going to try and strive as I record future episodes to stick to that language do not say the homeless but you say people who are experiencing homelessness. And.

S3: Construction along those lines. Unfortunately there are two caveats. First these next two episodes including today’s were already recorded by the time I got that email so I couldn’t go back and retroactively fix things. I couldn’t retcon it. And. Second we already titled The series working with the homeless. It’s a little tricky to go back and redo that. So we’re going to as a sort of compromise stick with the title. But in the actual episodes themselves we’re going to watch our language. And with that.

S4: Let’s talk about we’ve got on tap for this week. I’m going to be talking with Bonnie Coover. She is a nurse practitioner Janeen medical care and she runs their street medicine team. Essentially she is a nurse who provides primary care to people experiencing homelessness. She goes and visits them. They sometimes come to her and this conversation was both a way to learn about the challenges of practicing medicine out on the street. And it’s also a way to learn about the kinds of maladies that tend to afflict people who are homeless. One warning ahead of time this episode does get a little bit graphic.

S5: It points not going to describe how but just be aware of that if you are easily grossed out. Be prepared. There are a few moments things get a little bit graphic. All right now that I hope you enjoyed chef.

S6: What’s your name and what do you do. My name is Bonnie Coover. I’m a family nurse practitioner and the director of street medicine at Jamison medical care on a day to day basis. I see people who either live in the street or live in a safe haven and do primary care for them I do urgent care and that’s the big picture. What I do.

S7: So you’re a medical professional who your clients are the homeless for the most part.

S6: Yes. Yes I get referred clients to me through outreach teams who work with people who are chronically street homeless. They refer people to me to see and then those are the people who you know we start a patient provider relationship. And is that all of genius clients. No genius provides health care and a variety of settings. So the street medicine program is just one of the programs. We also have onsite health care in temporary and permanent supportive housing sites so for people who are housed either like I said in a temporary or permanent place there are is like onsite medical care. I write up a Chadian but my portion of it is the people who are currently street homeless though I do go into the safe haven sometimes if they don’t have health care. You know I’m seeing somebody they move into a safe haven they were on the street and they move into the safe haven I’m not going to just stop seeing them.

S8: So how many years have you been a nurse for a little bit over three years three years and I’ve been doing this job for a little bit over three years. This is your first nursing job. Yes. This is where you started but it’s a dream job. Isn’t nursing a first or second career or is it more like a third or fourth third or fourth career. Yeah. How did you get into being a street medicine Nurse What led you here.

S9: Well when I was graduating I knew I wanted to serve some underserved population some population that didn’t have the access that other people do have. And in school one hour rotations in a community clinic in the Bronx and it was a clinic that happened to serve a lot of people who were either in shelters or like unstable house do you know couch surfing. And I think that’s what got me to be aware and connected to serving that population and also like aware of it as a really specific skill set when you’re taking a history from somebody who may have a more chaotic time in life you know maybe maybe their brain is a little bit more chaotic. Sometimes I’m not saying that for like every person who’s unstable housed but it can be a very different way that you even conduct a medical visit bedside manner matters a lot.

S7: I imagine. Yes compared to yeah you have to that’s that’s like a whole specialization right there.

S9: Right. Well you have to have more time than you do in a traditional setting. I mean there are plenty of clinics who serve people who are unstable housed or in shelters and they are sort of on a traditional schedule where you have to see a patient every eight to 15 minutes you know and just like that’s how billing works that’s how you like pay the rent to have a clinic open but that works differently for you guys. Right. Right. We work on a grant and that allows us to spend as much time as we need with each person just to be clear.

S7: Are you seeing people out on the street for the most part are you coming to them or are they ever coming to you about half and half.

S9: I would say you know some people when they’ve developed a good good rapport and trust and outreach team they’ll come to the outreach office because they have a good relationship with their case manager. So maybe I’ll see them while they’re at the office and then people who are not really I’m not really there yet. You know that they really are at their street location 24/7. Then I go to see them. So the street medicine team consists of myself or another nurse practitioner or M.D. and then also one R.N.. So we will. The outreach team you know they have a pretty large client load. And then of those people if they are particularly metal medically concerned about somebody either because they don’t know what’s going on with them or because they maybe had a hospitalization or known chronic condition then they will you know refer them to us for sort of like ongoing treatment because we have you know like one teen that serves all of Manhattan and another team that serves all of Brooklyn and Queens. It’s not so much a you know emergency you know come over here right this second yeah has more either like it more like a standard primary care visit that you would make or more or maybe like an urgent care visit.

S6: You know sometimes you can get there you know in a couple of days.

S7: I guess if someone is in need of truly urgent care as any emergency situation they would hopefully go to an emergency room right.

S9: Hopeful. I mean that is what the outreach team would tell them to do but depending on the person and where they are in life right now they may or may not go. And depending on what they’re dealing with in their life you know that really changes like the hierarchy of how someone orders their needs you know might not be the same as if you have a stable place to live. You know if you leave your spot you can you know you can’t you know if you have more than you know a bag or two you can’t take that with you to the hospital and if you leave it that’s going to then it’s going to be taken. So you know sometimes people are having to choose between getting medical care if they go to a hospital or like losing all of their personal belongings.

S7: Wow. Yeah. And that’s the calculus they have to do right.

S9: So there might be times where exactly where the team the average team is thinking this person you know they seem like they have an infection you know they seem like they have pneumonia they seem they just seem sick. But you know they have other priorities that are going to prevent them from going. So then we’ll come out and see them and a lot of times that is the way we first engage somebody is they have some acute medical need or concern and then we engage them to see if you know if we can treat that whatever that concern is and then if they’re interested in ongoing primary care and we try to do you know really the highest level of primary care the same as like you or I would receive interest and so the goal is to treat what’s happening right there.

S7: If it’s a flu or whatever whatever it might be and that it’s to create a long term relationship. That’s what you actually you’re hoping to get out of it is someone who will then come back and check in.

S6: I wouldn’t say that it’s necessarily my goal to have the long term relationship because I really try to keep it patient focused and like what is their goal. But they should know that if they want primary care like that is something that they can access without having to like lose all their stuff or you know leave their spot for half a day and wait for hours in a clinic you know.

S7: And at that point once it’s a regular relationship is it that you’re kind of doing you will do house calls or. I mean that’s the wrong term to use here but corner calls I guess will say or is it that at that point they’ll start coming in or both.

S9: It just depends on the person. Yeah it depends on the person it depends on their mobility. There can be physical you know limitations to how hard it how hard or easy it is for them to travel. Like I said how much stuff do they have people who are struggling with addiction especially when people are really heavy users. They really have to spend all day making money in order to not get sick so they can’t spare a couple of hours to like go see me or anybody in a clinic because they may you know go in withdrawal during that time or just like lose out on like making money and then go into withdrawal later.

S7: So typically what are you getting referred to someone for what is a normal case.

S6: I would say they fit into maybe three categories one category that people get referred to us is just for for age. You know if somebody is like over 60 and still living on the street they’ve passed that like the average age of death for somebody who’s on the street. So it’s just probably good that they have a checkup. So we’ll go engage them for that. We get referred people who are like I said having an acute problem a lot of times it’s you know like a breathing problem or a lot of times a skin infection skin infection. Yeah a lot of skin infections a lot of lower leg wounds lower leg wounds like open cuts things like it’s not so much cuts.

S9: But unfortunately when people stay outside you know it can be not as safe to sleep lying flat. So like you know when people sleep say in the subway or Penn Station or a more public area people can choose more public areas because it’s more safe as far as like you’re not going to then be attacked by someone. But at the same time if you’re in a more public area you’re more likely to be told that you have to remain sitting up. OK. And since you know humans were meant to sleep lying flat when you sleep sitting up all the time your fluids pool and your legs and people end up with what’s called venous insufficiency and chronic venous insufficiency ulcers and their lower legs your skin basically just starts to break down from being overstretched for months or years. Wow. And then it’s really hard to heal and so that’s one that’s one really common issue that we get called for.

S7: And you said there was a third bucket.

S9: Oh right. So yeah. So the sort of like age and then like maybe an acute issue like a skin infection or something that know they’re worried about right then and then the third bucket I would say would be like a chronic condition like Oh we know this person has diabetes. We know they have hypertension. We know this person has a history of heart disease or they’ve had several hospitalizations. And I would say those are the sort of like three broad categories that people fall in too as far as why they’re being referred to us.

S7: If someone is just older and they’re still on the street you just told me is that person. The odds are they should be dead at that point they’re past the age where the average age where someone survives at that right in the street.

S6: I think I think the age is 57. Fifty seven I think is the average age of death street homeless.

S7: I mean that’s your if you’re in your 60s that you’re a lot of danger right. What is the move at that point with someone who is still living out on the street. Is it. No. Are you just taking care and hoping that you stay healthy or is it. There’s an urgency to get them into a safe haven. What do you do.

S6: Well you know I mean the statistics of fifty being the average age of death doesn’t mean that any one individual necessarily is sick. I actually have met a handful of 60 and 70 year olds who have been street homeless for literally decades and I can’t find a thing wrong with them. I’ve met a couple of older gentleman who do a lot of Canning a lot of Canning Yeah. So you know where you’re going and you’re picking up the recyclables and that’s how they make money. Yeah and that requires a lot of walking. Ok so I’ve heard better. Like really fit having a year old who would love to live on the street right.

S7: I’m just thinking about my own knee problems. The guy you’re describing to me I mean like physical therapy for the guy you’re describing right now could probably outraged me potentially great potentially. So there are exceptions to this to the rule.

S9: Sure but we just want to be sure and check on anybody who is over 60 because of the mortality but the assessment is essentially not different than it is for anybody else. As far as like you know making sure that they know that they can access our services letting them know that we can we’re happy to see them in an ongoing way for preventative care. You know vaccinations health screenings. Therefore if they don’t want us to come around they can just tell their case manager if they’re feeling unwell. Yeah and we’ll just come see them.

S7: There’s no point they were like hey buddy you’re like you really might want to think about a safe haven at this point you’re kind of chancing it out here.

S6: I think that you know their case managers are talking to them about housing. Yeah all the time. Yeah. And that’s now not nudging them. That’s not really my role. If somebody has a to go back to the venous insufficiency ulcer. Yeah that is something if they have especially a condition that is related to being outside such as Oh you have to sleep up and that’s why the swelling isn’t going away in your legs and we’re really gonna have a hard time you know getting rid of these ulcers unless you’re able to sleep flat. Yeah so I do bring it up when it is when their situation is relevant to their health in a direct way I mean it’s always relevant.

S7: Yeah it’s always an effect but I’m tired if there’s something where urgent can say if you had a bed this problem might go away. Exactly. You can say it in that context. Exactly. Whereas just telling them to go to a shelter is not productive. It sounds like that’s right. I don’t think so. Yeah. That’s the book you gave me when I initially said that.

S10: Like that’s a terrible idea. Well you know I I’d have that people have been to a shelter decided they don’t want to be in a shelter right.

S7: That’s. They’ve made that calculation. All right. So you telling them isn’t necessarily going to help that relationship that you’re trying to build with them.

S6: Right. Right. Yeah I don’t like to tell people what they need to do. Yeah. You know people people know what they need and it may not be the same choice that I would make. But you know you got to give people the dignity of knowing what’s best for themselves. You know some people don’t want to go inside because they really can’t tolerate being around other people. Yeah you know that it stresses them out or they feel anxious or you know even in a safe haven which is you know typically from what I hear from people nicer than the shelters and less stressful in the shelters. But it can still be too much for people so you know you have to just accept that people know what they need when you do find someone with sort of an acute condition like there’s ulcers.

S7: What do you do for that person. Like what. How are you treating them.

S6: Well for chronic venous Stacey’s ulcers we really go through details of like when there might be opportunities for them to elevate their legs. There’s nothing like getting the swelling to go down and kicking your feet up for venous basis. So that’s one thing that we do is we just you know we really talk through somebody like what is their typical day like if they can’t sleep flat you know is there some place where they can be that they can put their feet up at least for a few hours and then we do compression either bandages or stockings and then we do wound care like routine you know maintenance not just depending how bad the wounds are. Depends on how frequently you do the wound care you know how much compression is wound care like cleaning and stitching or what does that mean you don’t really you don’t tend to like stitch up daisies also. So it’s more just like cleaning making sure it’s not getting infected. You know there are different types of bandages for the specific types of wounds and then compression as a nurse you.

S7: I mean you kind of or met any kind of medical practitioner you have to have a fairly strong tolerance for the human body for some gore. I mean does it take more if you’re working with Thomas or you love more.

S10: It was that that was the answer. Oh yes you love Gore. Yeah I mean I don’t love when bad things happen to people okay. But I mean I find the human body fascinating the reasons I went into this. Yeah.

S8: What what did you do before you said this is like your fourth career. Well I originally came to New York to dance which I was dancing if Black Swan taught me anything the human body.

S7: It was a lot of body hard dancing to the feet okay. But so you love Gore so you were really born to do this is kind of so but it doesn’t bother you at all. No.

S6: You know I did well I just find it’s really interesting. Yeah. You know how does the body work. Why. You know what makes it work. Well what what’s going on when there’s something going wrong with it.

S7: I guess what I’m asking for lack of a more delicate way to do it. But then you know I guess you’ve only been working out in the street homeless population but you know what you understand. Is it grosser the stuff you encounter with your patients than what you would ordinarily encounter in you know a more traditional population. I think so. Yeah. I mean you’re describing openly so ulcers on legs and wounds and things along those lines or are like a really common thing you’re telling me.

S6: Yes I do think that there is more quote gross stuff than you would see in a typical crowded ass. I’m asking the real 12 year old question because you know what. Yeah you I’ve had you know a fair amount of people who have been dealing with you know their flesh is rotting off.

S11: Yeah. Honestly because of frost bite or because of arterial insufficiency and you know people don’t access care in the traditional ways. You know sometimes people don’t always make the same decisions that I think most other people would make like in the case of frost bite. You know most people if they had a toe that was like you know frostbitten it was dead it was completely you know not coming back then the recommendation is that you get an amputation for that but you can do what is called Auto amputation which is that you don’t treat it and you wait for the digit to fall off.

S7: Is that a common decision that people make. Yes. Yes it is.

S6: Oh it is so. And in that case you know we do a lot of supportive care you know make sure that the person knows the signs of infection you know and if you’ve heard of dragging gangrene versus wet gangrene. I don’t know what’s what is the difference. Well OK. So dry gangrene would look more like like a mummy I guess. OK. A mummy skin. Have you ever seen a picture. Yeah. I’ve seen pictures. Was like dried out tissue versus what gangrene which would be where you’ve got the like the blood and the pus and the infection. Yeah. And so you know we provide supportive care to try to get it on the dry gangrene side of you know no infection and you know make sure the person is aware of signs of infection. Monitor and make sure that they’re not having a they don’t go you know septic where the infection doesn’t spread to their blood the rest of their body. Yeah I think rotting tissue that’s is what we’ve dealt with the most this far as the core factor.

S7: So that’s that’s a big concern when you find someone with some sort of open wound is keep you from getting worse. Yes. That’s always the like it could turn into a full long life threatening condition if you’re not careful.

S6: Right. Right. Yeah yeah. That’s true. And people just don’t have you know they just don’t have a lot of access to.

S7: You know it’s like do they have fresh water to rinse it off with you know I think about the medical decisions I personally make which are often horrendous and like that don’t ask me about my I still write like and I am a comfortable upper middle class man with a good health care plan and it would not be hard for me to make better health care decisions for myself to treat little things when they come up or deal with injuries before they become chronic. And so when you’re dealing with I guess for a person on the street I mean they have so much more that standing in the way of getting care. They have to make those decisions like you know whether or not they leave their belongings behind to go visit you or something like that or I mean they just they’re doing a totally different set of mental math. You know it’s even harder for them to head off things before they become a real problem. Yeah they can be. They can be. I’m kind of thinking out loud as I’m just contemplating like I’m finding a lot as I talk to you know people in this field that they’re little things that just wouldn’t occur to me that like oh yeah. That’s that becomes a big decision for that person or that’s something that you’d have to deal with a totally different way.

S6: Right. One of the first things I we’re learning is that some people don’t want to have pills on them even if they have no street value just having pills can make you you know appear to be a target. Oh like somebody sees you like pulling pills out of your pocket. Somebody might want them. You know they don’t know what the pills are. That that could make you a target. Yeah I don’t know it’s just Tylenol right. Yeah. Or in the Fed opinion for your blood pressure and that’s kind of a third bucket.

S7: You mentioned it’s just chronic illnesses. Mm hmm. Mm hmm. What are the challenges of treating so for a chronic disease when they don’t have a home like how does that change your job as a doctor or as a as a practitioner.

S9: I think that mostly you know it is driven us a lot to as much as possible toward you know long acting treatments. There’s you know one weekly patch you can do for blood pressure. Like I said I wish there were more options but there’s like there’s one you know you can do that there’s you know a couple of like injections you can do that’s like a weekly injection for diabetes so we really focus on those at least weekly treatments or monthly treatments you know because then I can go or the R.N. can go or one of the other practitioners can go and actually administer that medication weekly so the person then doesn’t have to you know keep up with it or you know in the case of diabetes medications many of them need refrigeration they don’t have to worry about that or just you know the general difficulty of keeping up with a lot of things. Yeah. Getting your ass.

S7: Yeah taking your medication every day is. Yeah. Well tougher then.

S6: Yeah. That said some people do really well. I have a couple of people who you know always take their blood pressure medication on time always take their seizure medication on time we help with reminding them to you know pick it up or sometimes we go pick it up for them.

S7: You know if people have a hard time traveling or paying for medication how do they get their meds is covered by Medicaid or how does it work.

S6: Most people are connected to Medicaid the outreach teams you know sign anybody up for Medicaid who’s eligible. And since New York is a Medicaid expansion state most people are eligible. Yeah. Which is really great. And then if somebody is not eligible for Medicaid but needs a medication we’ll pay for it.

S7: You guys will use your grant money to make sure that person’s got there. Yes. What are the most common chronic is that diabetes like what is what are the things that these folks deal with.

S6: Some things it is the same chronic illnesses that every primary care person sees which is yes diabetes heart stuff hypertension heart disease some things that are a little bit different about street medicine would be more people will die of cancer than the general population. I know that cancer is one of the top three things that kill people who are homeless and I don’t know exactly why but from my observation it seems like when I know a person who has cancer who’s you know you’re homeless or unstable housed it kind of feels like the way people used to talk about cancer like in the 80s I don’t know exactly how old you are but I don’t know if you remember what it was like cancer. And that just means you’re going to die and that’s it. And that’s how they tend to think about it and that yeah it’s like you know if somebody has like a lump and they’ll tell me they’ll be like Oh I I’m afraid I have cancer. And the implication is that I’m afraid I have cancer and therefore the end is near and I should just pack it in and enjoy my life like Han. And and also and I don’t want to go somewhere and have somebody tell me I’m going to die. It’s too scary.

S7: How do you how do you deal with that situation. What do you do.

S6: Well I try to have conversations with people you know and tell them you know it’s possible that you could be cancer it could not be cancer. You know I depending on the situation I give them my best you know medical My best guess as far as like this is consistent cancer or like this is not consistent with cancer. And then you know even if it is consistent with cancer I try to just educate people that you know a lot of cancers if they’re caught early you just cut it out and then you’re fine more or less. You know obviously there’s like some monitoring you want to make sure it doesn’t come back. But I try to just let people know that you know the earlier you go check it out the more chance that you could just have a surgery or some treatment and have many more years onto your life it’s not necessarily a death sentence you’re there telling them that they shouldn’t just quit or they don’t have to just quit right now.

S9: Well yeah. Just just because you have cancer or you think you have cancer that doesn’t mean it’s all over.

S7: Yeah yeah. And that’s even though that’s the perception and that among a lot of homeless folks from my experience people I talked to yes.

S6: That’s strongly the idea is that you know if you’ve got a lump and you don’t know what it is yeah you’re done.

S7: Yeah with conditions like hypertension diabetes are are your patients any better or worse would you say about keeping up with their treatments than you know a normal patient.

S6: I don’t think so. No that’s that’s an area where I would say it feels more similar to really traditional primary care at least the primary care that I practiced as a student at the clinic that I was in where you know people don’t take their high blood pressure medication because they don’t feel bad you know. Same thing with diabetes. You know they don’t they don’t take the medication unless they feel bad and are in all the work is in you know educating people about how you know OK you don’t feel bad today. But like in 10 or 20 years you’re going to be on dialysis.

S10: It’s terrible. You know you’re going to it’s your eyesight you know down the road.

S8: Yeah. So it’s the same that same stuff. Yeah. That seems very similar.

S7: Yeah. People are stubborn and don’t follow instructions no matter who they are how much money they have.

S6: Yeah well I think also I think that I mean whatever this is my theory of like it’s here in health culture in the U.S. at least is that we have this whole concept of like a sick person and a healthy person. And if you have to take medication every day for the rest of your life I think there’s this conception of like you’re therefore a sick person and people don’t want to think of themselves as a sick person.

S7: Yeah you know they’ll do anything to convince themselves that they don’t need to take their meds right. Because they feel fine. Yeah. Which they are not. Even though they they frankly are like you.

S6: Yeah. It’s like you feel that you’ll feel good for a lot longer if you just take them. But what do you carry with you.

S8: Like when you’re out on a visit like what’s what’s your gear.

S9: I carry some like really basic diagnostic tools so you know blood pressure cough stethoscope pulse ox for the you know oxygen saturation thermometer. You know some really basic things as far as that goes. And then as far as treatment I carry you know a couple of different antibiotics. I carry an inhaler some wound care supplies you know a couple of different antibiotic creams I guess. Earlier when I said and by accident. All right.

S7: So you know a couple of forms antibiotics some creams some wound care so a little bit of medicine a little bit of basic diagnostic tools and a little bit of first aid sort of the mix that you’ve got on you.

S9: Right. And then if there’s anything that like somebody needs urgently and for some reason I’m not going to like see them again or you know there’s an urgent situation like I will go purchase something. But more often than not like that will cover it or you know they have Medicaid and I can prescribe them what they need Yeah or I can see them again the next week and bring something else.

S8: And do you buy a car or is it a van or near you. What do you what do you driving around it. We did recently get a van. You’ve got a van. Mostly we walk around and take the subway. Oh really. Yeah. OK so you’ve got your gear in like a Yeah bag with you. Right.

S9: Well that’s in Manhattan. So you know there’s also our teams in Brooklyn and Queens there and cars more just because the burros are more spread out. And then we have a medical van that’s shared between Manhattan and Brooklyn Queens. So it’s a small thing. It’s not like a big Winnebago. It’s a sprinter.

S8: I don’t know if you’ve seen a like delivery van. Yeah. Dodge Sprinter it’s not that. No not Mercedes. Mercedes Sprinter. Oh OK sprint. Yeah.

S12: And we got it you know tricked out so I wish I had get spinners on it but they said no. You asked. Well I think they thought I was kidding it arrives.

S7: I’m sorry. This Mercedes is not have the Rams I requested.

S10: Yeah it’s got the medical bed in like a centrifuge and EKG and like all the bullshit. Yeah. Medical care whatever for medical care.

S6: Yeah. So yeah we trade off use. Yeah. Of the van which is really great because you get the privacy.

S7: Yeah I imagine that’s going to be if you’re if you’re patient. That’s that’s what a few moments of privacy you might get in a day.

S6: Yes. Well Brooklyn and Queens people have more privacy I think because it is more spread out. OK there’s more bridge underpasses and stuff where there is low traffic. There are places like that in Manhattan for sure. But more often our clients in Manhattan. Yeah. It’s like I’m trying to you know ask personal medical questions on 30 Fourth Street and you know and it’s just like everybody else you get the anonymity of the massive crowd is the best that you get.

S7: So it’s if you’re having your checkup in the middle of Herald Square. No one’s really listening.

S6: Sometimes sometimes we do have issues especially like when you earlier you ask about the Gore when we’re doing like wound care and it’s it is more gory. Yeah we’ll stop to look like the show. Oh that’s. And I’m like this feels terrible. Yeah. So I try to do the wound care and then also like keep my peripheral vision open for you know Oh is somebody coming. You know me trying to just get like a free entertainment for the afternoon so that I can stop and you know try to get them to move along because I feel like that’s not rude I’m going to ask a question.

S7: It’s kind of like my faith in humanity might actually depend on your answer here but has anyone ever tried to like snap a picture of it or like Well have you ever seen someone trying to take a pic. I don’t know that I would let anybody linger long enough I’ll get a picture. OK. Yeah. I just like whenever you like that because when you say like people are rubber necking that was what I was picturing for a second. It’s like that would be. That’s my faith and you managed collapsing right there but now thankfully I haven’t seen that. No I think people just want to like stop and watch you know like you’re watching someone’s checkup up here or like watching someone like him very intimate like right.

S6: Yeah right thing here. Yeah some of it does go the other way though sometimes people stop especially when you have somebody who is. In a location for a long time where there are community members that know them OK. Sometimes people will stop to like make sure that we’re not hassling the person which is really nice. Yeah yeah. That is like they have people like looking out for them and then that you know the person that the client that we’re talking to will say no no no it’s fine I’m good I’m good you know. Yeah. And I’m like Oh that’s great that’s great. How many people do you typically see in a day. It really depends. We usually put seven or eight people on the schedule and then sometimes you find everybody and sometimes you find nobody really. Rarely do we find nobody but you know usually be a mix of like some people who’s just come in. Some people that we go out in the field to find but it really really depends. Yeah

S7: I just felt like they may not be where you expect them to be on a given day or right but sometimes you roll snake eyes and you get nobody in a day.

S6: Yeah rare. Rarely do we get nobody but occasionally and also like usually we have backups you know where it’s like well you know you plan a route where you’re like Well we’ll go see this person if they’re not there there’s this other person a couple blocks over you know you’re always playing a lot of backup people you need to be pretty flexible you need to be very flexible to people who show up for their appointments and they come to you or do they are there are they good about showing up to their points I should ask some are some aren’t. It really depends on the person and what’s going on and usually you know the day before they’ll be like a last minute person or two thrown on the schedule who’s maybe having like a crisis or you know particularly maybe outreach went by and saw a like a really gnarly wound want us to go check it out Hey get over to Bonnie quick.

S7: At one point you mentioned that taking a medical history can be a little bit tricky especially if someone was I assume a mental health issue or you said kind of a little bit more disorganized. Mm hmm. How is it different. How do you go about it.

S9: Well always my priority is the relationship with the person especially if somebody may have schizophrenia or other serious mental health issues.

S6: That means to me that they may in particular have had bad medical experiences in the past. So I always want to you know I try to pay attention to how somebody response the questions and if it takes you know over the course of several visits to get a complete medical history that’s usually actually more how it works I say versus getting it all you know in a first visit. Certainly not Yeah or a second.

S7: So you’re collecting info over time as you get to know them.

S6: Right. Right. And I think what can be difficult of taking a medical history when somebody is somewhat disorganized mentally is that you know they tell you things and it’s hard to tell what what happened or what did not happen or when it happened maybe. And so it’s sort of like you know you look for you look for clues. I mean honestly it can also be really difficult sometimes figuring out what’s going on with somebody in that moment. Some people who not everyone but some people who experience schizophrenia have a hard time feeling their own bodies. In particular some people seem to be really insensitive to pain. So looking for you know asking questions about people’s you know behavior can give you. Like I knew a gentleman who had like a chronic pancreatitis. He didn’t ever seem to experience any pain. So I really focused on you know and asking him about like well like have you thrown up you know something that a little bit more like concrete or I knew another gentleman who you know had had several of his toes amputated because of frost bite. And when I was really talking to him about the details I was trying to get him to let me see his feet so I could see if he was getting any more frostbite and he was telling me that his feet felt fine.

S9: You know normally you would have considerable pain with frostbite but because I knew that he had was fairly disorganized I ask him about you know when he had frostbite previously you know well what did that feel like. And he said oh I felt fine. I didn’t feel anything. And I said What about amputation. He was like No it was fine I didn’t need any pain medication. And I talked about you know well what did your toes look like. Cause he was telling me when the doctor said oh see all of these toes like they needed these like six or eight toes need to be amputated. And I said Well what did they look like to you. And he said they looked fine to me. They looked like normal foot skin was what he said at that point what did you do. Well I just worked on building the trust in our relationship until finally he’d like you right back.

S7: Right.

S9: And he did eventually actually for him even though he had been outside for a very long time. And he actually ended up going into a safe haven and the safe haven was connected with like a medical service. And he let the either a nurse or a doctor there see his feet finally.

S12: So it’s a great somebody saw Sophie someone talk about a months long project whatever.

S7: Yeah. When you’re treating someone with schizophrenia or another mental illness are you ever worried about them potentially getting violent. Are there any safety precautions you have to take.

S6: I mean we take we take some safety precautions with all of our clients you know like you said we are referred people through the outreach team and we always ask if the person has a history of violence or is at risk for violence for any reason and if they’re in a secluded place we always have somebody to go with us. But for the most part I see most of my clients on my own and most people are not violent. I think there’s a I don’t know if it’s come from movies or what but it seems like people equate schizophrenia with violence. Yeah and I know certainly some people who are schizophrenic or violent but plenty of people who are not schizophrenic violent too. Yeah but no but the vast majority of people schizophrenic or otherwise. No there’s no concern for violence.

S7: But we always you know we ask if there is any history do a lot of your patients have drug use issues. Would you say yes.

S6: Yes I see a fair amount of people who either deal with heroin use or alcohol use. Usually they it’s not just substance use on its own. It’s usually coupled with PTSD or other like severe early trauma.

S7: How does that change your care program for them. What happens at that point if you know if you know someone for instance injecting heroin while someone’s injecting heroin.

S9: One of the things that I always try to do is you know establish that like establishing a relationship the trust that like I’m not going to judge them for any thing that they are doing in their life and that my goal is to you know provide resources that they can be as healthy as possible.

S11: So now if that is they want to get on into treatment in a methadone program or if I can prescribe Suboxone for them then of course I want to do that. And if they’re not interested or they’re not ready to do that then I want to make sure that they’re connected to a clean needle exchange program that they know about like using alcohol swabs before they inject so that they don’t you know end up with endocarditis or cellulitis. So it does change it. I think it helps me ask better questions it helps me be more mindful about like what they may need.

S7: You’re doing a lot of harm mitigation as well as or harm reduction harm reduction. Yeah. How often would you say they they take you up on the offer to try and go to a clinic versus taking your advice on clean needles or how often do they just ignore it altogether.

S6: So far in my experience everybody who has been at least addicted to opioids has eventually been interested in treatment or they aren’t interested in treatment but they’re like not quite ready. So it’s more a matter of when than if and people. Yeah people I mean people are I think sometimes they’re you know they’re just a little bit secretive because they’re afraid of being judged.

S7: And it comes back to establishing trust like you said right.

S9: But most people are interested in. Yeah and like clean needles and you know those sorts of things which are a lot of good programs in Manhattan not quite as many in Brooklyn and Queens.

S12: What is the part of your job you enjoy most other than the Gore talking to people.

S6: It’s like getting to know people.

S13: I think that people who are experiencing homelessness you know I mean everybody sees somebody who at least appears to be homeless on a pretty regular basis.

S6: And it’s I don’t know it’s like it’s a whole other world that’s happening it’s a whole other community. I guess you know some people wonder what it’s like to go to the Met Ball and be part of that community and I’ve what I’ve always wondered like what is it like you know what is that that community like and I love talking to people. So that’s my favorite part.

S13: What would you say is the hardest thing about your job I think the hardest thing about my job is when you feel like you get really really close to helping somebody. And for some reason or another you just have that that bear Miss.

S8: You know. Yeah there’s something in particular you’re thinking of.

S6: Yeah yeah I just there was just a gentleman. He

S9: actually just passed away on Saturday and we almost got him into treatment for a treatable cancer. Yeah it was. He had a treatable cancer. And he you know originally was very much thinking that oh I’ve got cancer that’s it for me.

S13: And he but he was open to treatment. He was you know he was like we’d go to some appointments missed some appointments. Yeah. It was in his. It was in his throat. And it ended up I don’t know. I think if he was there I think if you would have just gone to like a couple more appointments a little bit earlier there’s very real possibility that he could have had had it treated and lived another 20 years. But because I think of that for whatever reason the like really pervasive fatalistic ideas about cancer among that community he was ambivalent about it because he kind of thought he was already dead and it made it come true. I got had a C.T. scan from him like maybe like just six weeks ago that showed that it hadn’t metastasized at all.

S9: So it was still like localized to one spot and it could’ve gotten it. Yeah.

S12: Sorry. That’s kind of. No no. That’s why I asked.

S6: But when you win you win big. When you win you win big. Yeah yeah. You get to like save lives and save people’s legs. And yeah you know because otherwise they weren’t going to get treated for that thing.

S14: Yeah. Sarah. Yeah. Thank you for coming in here today and sharing all that. It was nice to meet you.

S4: That’s it for this week’s episode of Working I hope you enjoyed the show. If you did please please please leave us a review at Apple podcasts.

S2: And if you have questions comments thoughts little corrections for me like Maura did send me an e-mail. Working at Slate dot com. Like I said I love to hear from you again. That is working at Slate dot com. As always working produced by Jasmine Marley a special thank you to Justin de right for the add music. My name’s Jordan Weissman. Catch us next week.