September 5, 2017

Peanut butter and tokens

My patient turned her head away from me, her affect flattened from the last time we had spoken. I asked if she was ready to leave, and told her she was being discharged so she could seek a place to stay through the local shelter intake. "It doesn't matter when I get there. I'll have to sleep on a chair. I'll be back here tomorrow." Her eyes were doleful as she looked at me, then rolled over toward the window. Our conversation was over.

All week we had been fighting and working with social work to make this patient's discharge a possibility. She no longer had any medical reason for remaining in the hospital; now, it was just the looming forces of homelessness, mental illness, and desperation that kept her on the antepartum service. She had been living with a neighbor of sorts, but her possessions were abandoned outside when she came into the hospital. She had a transit pass before, but it had been lost. We gave her tokens. She had a glucometer before, with test strips, but that had been abandoned with her belongings at the neighbor's home. We found an extra glucometer in a desk drawer at our clinic and ordered more test strips and lancets. The fact remained, though: she had nowhere to go.

What does it mean to discharge a patient who is homeless? There is a sense of futility, a bitter aftertaste of cruelty when you sign an order that spits a patient back out into the world with no place to lay her head. There can be no joy in your voice when you tell the patient that she "gets to go home," because you know the phrase is meaningless - worse, it is hurtful.

My patient has another issue as well - she is diabetic, on insulin. I write a letter on letterhead, cosigned by my fellow resident and by our attending, that explains that she is pregnant and diabetic and desperately needs a place to stay and consistent meals in order to be healthy. I knew the food in the shelter would not be satisfactory - likely carbohydrate heavy and inappropriate for a diabetic pregnant woman. I almost left the hospital to run to the store, a few blocks away, to buy her a large jar of peanut butter. I wanted desperately to do anything to keep her healthy and safe without having to hold her in the hospital.

Her words resonated with me - a promise that she would return, with any possible complaint, to be seen in triage and possibly admitted again. She knew, and I knew, that her fetus might have another deceleration requiring further monitoring. It would be easy for her to be readmitted.

I was not surprised when she called the Labor floor the next morning, while I was on call. Neither one of us stated the obvious while I asked about contractions, or leaking fluid, or if the baby was moving appropriately. She told me she was contracting frequently, and I had no choice: I told her to come back for evaluation. When she got to the triage unit, we put her on the monitor and she fell fast asleep: finally in a quiet place, with a bed, and a chance to rest.