It’s taken awhile, but Mr. Green, a heavy drinker, is finally sober enough to be discharged from the emergency department. As I examine him, I note that his scuffed hands aren’t shaking. His speech isn’t slurred. His gait is steady and proud. But he’s homeless and the clock shows 1:35 a.m. and we have a problem.
It’s a problem that can’t be solved without creating another one. And the root of it, sadly enough, is compassion.
When an emergency medical services team pushed Mr. Green into the ED seven hours earlier, the alcohol in his bloodstream was at a level that would send most social drinkers into a coma. His body shakes with withdrawal at a blood alcohol level where most people are considered drunk. We’ve monitored him meticulously, striving for that sweet spot of intoxication where he’s functioning as if sober.
Since he’s been in the ED almost every day for the past week, twice in the past 24 hours, and too many times to count over the years, the ED staff knows Mr. Green very well.
As I help him up by the elbow, I can almost feel how my feet slid on the icy pavement when I rushed to start my shift. How the freezing wind slapped my cheeks. I recall how I rejoiced in the warm chaos once the doors of the ED shut behind me.
Discharging Mr. Green means he will spend the night on the streets. How can I send him to endure the same brutal conditions I was so thankful to escape from? Providing compassionate care means letting him sleep until daylight when the shelter doors open.
Except the waiting room is filled and every bed is occupied, some by patients who are being evaluated and most by those who are boarding in the ED until beds open up in the hospital’s wards and ICUs. The exodus to hospital beds won’t happen until late morning and early afternoon, so we need every bed possible to tend to those who are waiting to be seen and those who continue to arrive.
The crisis of emergency department crowding turns the bed occupied by Mr. Green into a scarce resource. But it also forces physicians like me to allocate compassion.
Compassion involves being moved by the suffering or distress of someone else, often followed by the desire to provide relief. And yet, like many things in clinical care, compassion involves risks and benefits.
The trade-off for my compassion care for Mr. Green — letting him sleep safe and warm — involves separating him from his alcohol and putting him at risk for withdrawal. Sleeping too long can result in medical harm. If he was on the street, he’d “treat” himself by drinking again. I can stave off his alcohol withdrawal with benzodiazepines, a class of drugs used to treat anxiety and other problems. A side effect of these medications is sedation, potentially delaying his discharge in the morning because he’s too sleepy.
Besides, what am I actually doing for Mr. Green? I’m not helping with his core problems: alcoholism and homelessness. He’s already been in and out of detox programs. Social workers have tried to help him. And whenever he’s admitted to the hospital for alcohol withdrawal, he walks out.
Severe mental illness afflicts up to a quarter of all homeless people, so it’s hard to know how much Mr. Green can help himself. At times I feel complicit in his behavior, satisfying short-term needs on his road to self-destruction. But emergency physicians trade in misfortune. Most people are a few bad breaks removed from Mr. Green’s three layers of pants.
Protecting him from the ravages of a bitter-cold night could save his life. Hypothermia is a preventable tragedy. It kills around 700 homeless or near-homeless people in the United States each year. The decision to hold Mr. Green until the morning isn’t necessarily what good doctors do — it’s what good neighbors do.
Sadly, there are several patients like Mr. Green in the emergency department. I’ll grapple with such compassionate care decisions multiple times during the night.
If there were plenty of beds in the emergency department, we could attend to patients with acute medical problems and make space for those with social ones. But there aren’t. So making a compassionate decision for Mr. Green means making a risky decision for patients in the waiting room. Crowding and prolonged waits in the ED have been linked to higher inpatient mortality, longer length of stay in the hospital, increased medical errors, more harmful cardiac outcomes, and delayed treatment for pain.
Moving patients from the waiting room to an ED bed as expediently as possible is the best strategy for timely and accurate treatment. The tired grandmother could be having a heart attack, the anxious entrepreneur could have a pulmonary embolus, the sleepy young man known for abusing drugs might have a brain infection.
The diagnostic process can be challenging, even tormenting, but it doesn’t eat at my heart in the same way as what to do about Mr. Green, where I’m forced to choose between two potentially tragic outcomes.
And should Mr. Green be found frozen after being discharged from the emergency department or should a patient die because it took too long for her to be evaluated, will anyone bother to consider the pressures that led to these outcomes and that compassion, not insensitivity, might be partly to blame?
I walk out to the waiting room’s triage area. Most of those in it have relatively straightforward and simple problems: twisted ankle, cough, medication refill. Problems that don’t require prolonged work-ups and that won’t burden my nursing colleagues who are busy triaging the constant influx of new patients.
As I walk among the swell of people waiting to be seen, some of whom might be quite sick, letting Mr. Green stay in the emergency department to keep him out of the cold reeks of unfairness. I want to care for these folks as much as I want to care for Mr. Green. The need and frustration in the sea of faces chills me more than the harsh conditions outside.
I discharge Mr. Green. As I watch him leave the ED, I’m off balance and feel sick to my stomach. Less than an hour later, a different emergency medical services team rolls him in on a stretcher. I’m relieved that he’s safe and disheartened that he’s back. His alcohol level is four times what it was when he left, likely due to the alcohol he keeps stashed in places near the hospital.
At least now Mr. Green is out of the cold. And he’ll wait. Waiting and warmth will stand for compassion, at least for the moment. Problems weren’t solved but moved around, a perfect metaphor for how our health care system currently operates.
Jay Baruch, M.D., is associate professor of emergency medicine and director of the Medical Humanities and Bioethics Scholarly Concentration at the Warren Alpert Medical School of Brown University in Providence, R.I. The patient’s name and identifying details have been changed.