For the past four years, this is James Beck’s routine: After a morning spent guzzling $5 vodka, he stumbles into a Dunkin’ Donuts parking lot, lying on the cement with his dusty oversized coat splayed open to reveal a cachectic chest. A concerned patron (cigarette and coffee in hand) will call 911 and, in accordance with protocol, an ambulance will deliver him to our emergency room.
Upon his arrival, we unpredictably greet our guest, sometimes with a jovial, “Hey Jimbo!,” other times with rolled eyes and a reluctance to approach the stench of his urine-soaked khakis. James, too, is unpredictable: occasionally flashing toothless grins and chuckling, other times shouting expletives and vomiting onto the floor. Two slices of hardening wheat bread glued together with grape jelly and a smear of peanut butter: that is all that James asks for. A stretcher and a diet soda would be nice, he says, but he’ll settle for a chair he can spend another twelve hours slumped in, safe from the blowing snow and unforgiving streets.
During each visit, a nurse, tech, and doctor examine James. They take vital signs, listen to his crackling lungs, order X-rays when he falls, provide IV fluids, or dispense ibuprofen to lessen the ache in his bones. Every month, Medicare pays over $10,000 for this modicum of care. There are no doubt thousands of James Becks throughout the U.S., occupying beds and consuming resources while other patients wait for space.
One Friday, as I auscultated James’s heart, he drooled on my stethoscope while grumbling, “get me a ‘P.B.J.’ sandwich, bitch.” I hissed back at him, exhausted. “Sorry, James. You came to a hospital, not a restaurant or a hotel.” I did not feel cruel; I felt empowering. Not giving James daily meals and shelter, I thought, would incentivize his recovery. He might attempt rehab again and perhaps stop over-utilizing an already anemic social insurance system, a system so burdened by homeless that some hospitals have even begun paying their rent to lessen their costs.
Yet one month later, James was still frequenting the ER each night; more malnourished and less sober than ever. He has been kicked out of every detox, shelter, and halfway house in the state, but the emergency room cannot and will not turn him away. Simultaneously, premiums continue to rise, providers become exhausted, and emergency rooms overflow. James and patients like him beg the question: what do I as a clinician owe someone and how is that different from what I as a human being owe them? When Hippocrates decreed, “first, do no harm,” did he anticipate quandaries such as these?
I now begin each shift by setting aside a hot meal for my inevitable visitor. In doing so, I puncture another small hole in the hull of healthcare’s financial ship, but I also temporarily relieve the gnawing hunger Mr. Beck’s belly. We spent Thanksgiving evening together in the ER, talking about dogs, The Beatles, and the merits of cranberry sauce. The belly laughs we shared helped me forget I was 2,000 miles from my family. The next day, I outfitted him in new clothing and tried to set up housing and rehab for him, only to have him mysteriously disappear during the time I said I would pick him up. In his piercing green eyes, I see tragedy, but I also see the beauty of humanity; a beauty that makes caring for James (and practicing medicine) both an honor and a privilege.
Molly M. Murray is a physician assistant.
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