The least of these...

Back in the day, when I was a tech in Albuquerque at a busy, downtown ER, our hallways were literally lined with stretchers holding homeless drunk guys every night.  Particularly in winter.

It was a constant source of frustration for the staff at the ER to spend so much time and energy, essentially, being a homeless shelter.  Especially because, as a rule, they tend to be very unpleasant, demanding, uncooperative and a risk to themselves and staff when they belligerently insist on trying to get up and leave while still very drunk and unsteady on their feet.

I became locally somewhat famous among the homeless population because of my fervor for a particular adherence to the letter of the law where vital signs were concerned.  In ER, every patient has to have vital signs done at least every 2 hours.  So, I would dutifully and cheerfully wake every single homeless guy every two hours to check their vital signs and assure that they could be roused.  Just doing my job.  But, knowing that they weren't going to get a good nights' sleep if they came to my ER, they would elect to be "found" closer to other facilities.

Over the years and in various cities in several states I have taken care of homeless drunk folks (not all homeless are drunks, btw, but the drunks are the portion of the homeless population who make most use of ERs).  I still make sure that they are made aware that the ER is for medical care and not a soft, warm bed for the night (or day as I primarily do days shifts now).  There are generally beds available at local shelters, you just have to show up by a particular time and not be drunk.  But, also, a certain amount of diligence is necessary because long term alcohol abuse puts one at risk for quite a few legit medical emergencies and some of them (bleeding into the brain for instance) can easily be mistaken for intoxication.

I was reminded of this years ago when I had a patient, I'll call him ICY, who -- as I was told in report -- had been witnessed to have fallen and bystanders called 911.  He was well known to EMS staff as a homeless alcoholic.  As I was taking report, ICY was walking from his stretcher to the bathroom.  His gait was a bit wobbly, but he made it.  I waited for him outside the bathroom and made sure he got safely back to his stretcher, got him undressed and gowned, got him a warm blanket -- for which he thanked me profusely and was generally just very sweet -- checked his vital signs and then sent him off to CT.

About 30 minutes later, I went in to recheck on ICY.  I couldn't get him to wake up.  At all.  I checked his pupils.  Not good.  One was about 3mm the other was probably 6mm.  He was breathing, but irregularly.  I put him on the monitor, rechecked his vital signs and discovered that his heart rate was slow, his blood pressure had a larger than normal difference between the top (systolic) and the bottom (diastolic).  Cushing's Triad.  Definitely NOT good.  He had pressure on his brain.  Just as I was about to go get the doc and let them know of this change, the radiologist had apparently called the ER doc to notify about the GIANT brain bleed that ICY had.

We pretty quickly intubated him and I got in a couple of big IVs and we gave him a powerful medicine to help reduce the swelling.  The neurosurgeon showed up  not long before I transferred ICY to the intensive care unit.  After looking at the CT, ICY's history and doing a physical exam, the neurosurgeon said to me, "This guy is going to die."  Yeah.  I thought so too.

Flash forward about a year.  I had left to go on a couple of travel assignments but was now back in the area where ICY lived.  Lo and behold, who is brought into my ER by EMS because he was found "down and out" by some kindly citizen who helpfully called 911?  Yes!  He was not only alive, but was now rocking a giant, old incision on his scalp that still had staples in it.  In the time I was gone, he survived his brain bleed after having had a hole bored into his skull.  He was sent to a rehab facility (no alcohol rehab, physical rehab) after discharge from the hospital, but then from rehab returned to his previously homeless state.  Rather than follow up at the local clinic or even return to the ER for re-evaluation after his ordeal, he just kept drinking and sleeping out of doors.  Predictably, he got an infection in his skull.  Yes.  The actual skull.  He ended up back in ICU having IV antibiotics and having part of his skull removed.  Now he'd been released again and still had his staples.  I finally convinced one of the ER docs that the better part of valor was to remove the staples.  I gave ICY a blanket and some food and, as per his usual, he was very sweet and grateful.

ICY has become one of those homeless alcoholics who could essentially give the ER as their permanent address.  He is known by name by all of the staff.  Most feel he is just another homeless drunk guy and are frustrated every time he returns.

Somehow, the lump of stone that resides just the other side of my sternum melts whenever I take care of him.  I always take great care to really look him over and make sure he's ok and then I get him a warm blanket and some food.  And, he is always very grateful and sweet.

And he makes me remember why I love being a nurse.