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.

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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.

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  • Sadly in the harm reduction rush we seem to have eliminated what were called dry shelters, places where patients ta le yours could safely sleep and perhaps make plans for a future. This piece touched me. We are all trying to do the next right thing.

    • This has nothing to dowith “Harm Reduction.” It looks like you jumped in on this conversation to justify the lack of any resources for people in these situations. They tie a lot of unrelated things together on certian TV programs, that does not mean they are related. This is brought to us by the same peope who beleive that kids need to go withoutt lunch if their parents can’t afford it to build character.

    • Yes Mavis, and it’s bought to you by politicians who think that giving away other people’s money actually solves problems (other than giving more power to government). See: war on poverty, great society, 80+ yrs of failed welfare state policy. Can’t wait to see what Medicare for all looks like. VT decided it was way too expensive.
      And yeah the war on drugs is bs too as is the incarceration rate in this country.

    • Sorry Greg Boger,
      You have it backwards. Our governemtn has been undermned and taken over by corporate intersts, leading to the situation we have now. Even our IRS has been understaffed underfunded and undermiend, while RW media runs a constant narrative about “big government.” The War on Povery failed becuase it was undermined and attacked from the start. The US already spend about 10K per American on our broken healthcare system, where CEOs make billions, and people die from preventable diseases. The media is complicit, they don’t cover all of the facts, which leads people to ill informed “opinons” like yours. In order to maintain these beliefs, it is neccessary to ingore an awful lot of facts. Besides every otehr developed nation has a national healthcare system, America is the only nation, where people go bankrupt or die, while billions go to criminal corporations. Medicare For ALl would save money, if theyrooted out the criminal behavior of the health providors, insurance companies, and pharma.

  • The problems created by politicians have landed on your doorstep and those who passed legislation that caused these problems in our society are fast asleep in their warm luxurious homes. Closing of mental health facilities and ‘community homes’, loss of all public community support is now your problem.
    I feel for you. Perhaps calling your local Representative at 2am and presenting him with the problem, may get some attention.

  • Yup, I was right about the side hustle thing. Dr. Baruch has his own writer/physician website. Nothing wrong with that! I loved Oliver Sacks, and Dr. Baruch does write nicely himself. But the piece does come off as simplistic. Everyone knows that every big city has homeless services, social workers, shelters etc. They are typically insufficient, often filled and turning away new clients – but not mentioning them at all is kind of bizarre.

    • “Providing compassionate care means letting him sleep until daylight when the shelter doors open.”

      “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.”

    • To people with money and no understanding of this it IS rocket science. Even sitting in a chair would be better than the freezing cold. I refuse to believe the hospital is so packed that there is no room for a guy to sit in a chair. The fault here is on the policies that stop this

  • Just do what most hospitals typically do. Discharge them, using the armed security guards now prevalent in all American Hospitals. Like thousands of other people like him, there migh be a liquor store nearby where he can go panhandle. This is how our locla religious non profit deals with alcoholics, drug addicts, and the mentally ill. Hosptials have been wares of these issues for decades, yet hey failed to do anything about it. They misreported the numbers too, they wanted to keep up their funding. Of course a lot of these individuals returned time and again, and they repeatedly “treated” them, taking money from charity and indigent funds. They freely kick out the under insured and ininsured to keep up their profit margin or in the case of the non profits their “extra funds” and exective pay.
    Silly articles like this obscure the fact that this happens every day. A young man in my community was shot 17 times by police after our local non profit refused to treat his scitzophrenia or call his mother. The hosptial launched a PR response to the death.

  • Shouldn’t you be in touch with your city’s homeless services to find a better alternative between for this man than freezing on the street and unnecessarily occupying in an ER bed? Does not your hospital have social workers on site to help with situations like this?

    • Sure seems like there’s cynicism out there about the way hospitals are being managed today. It would help if the author of this piece responded to the comments. Otherwise, it comes off like a doctor who’s starting a side hustle as a writer, instead of a good-faith effort to solve a problem in the healthcare system.

    • Mr Blau,
      This is the only format that doctors are allowed to use. Thousands of doctors and hospital staff ignore this problem daily. They are under gag orders and their careers would be ruined if they spoke up about this problem. They have been silent on matters like this for decades. Most of them chose to blame the homeless, for their plight. Some of them were well aware that these people kept returning to the hospital ER. As social safety net services were cut, and people lost their homes, this problem increased. Physicians at these ER’s got creative with denying care for low income or underinsured people, in order to save money for the hospitals. It might occur to them sometime, that there is a problem, but as long as the bottom line is protected they wil remin silent. This article falls under the category of Adversity Porn. Articles liek this give a false impression that some physicians are aware of the problem, and have compassion. The facts tell us that there are few or no services to fix any of this. The religios organizations, charities and non profits are incapable of adressing the bigger issues. The media misrepresents how effective any of these charities are. The comments on here reflect how a misinformed public, believes that there are options, other than the ER, when in fact they are limited.
      This goes on repeatedly at our local ER. They jokingly refer to these people as “Frequent Fliers.” Our hospital is a religios non profit, yet ehy have done nothing to analyze this problem, or address it. They give a small amount of their “excess capital’ to local clinics, in order to keep at least some of the population out of the ER. The local media presents this “charity” as more than enough. They do PR for the hospitla their largest advertiser. A scitzophrenic young man was shot 17 times by police officers, after he was released from the ER. The hospital PR spokeperson, blamed the scitzophrenic, and the local newspaper ran it, with no questions. The only coverage of local healthcare, is in the busiess section of our local paper. They are no longer covering the facts, only the PR, and the occasonal bit of adversity porn like this.

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