And We Call This a System?

Unidentified white homeless female. That was how she was first known to me in the holding room of the psychiatric emergency room.

She was too psychotic to be able to tell anyone her name, and when I came on shift, I was both fascinated by the mystery she presented and excited by the connection with my new work with Boston's homeless mentally ill population. I determinedly searched through her bag of reeking belongings looking in vain for some form of identification. I contacted my new colleagues on the medical team who worked with the homeless. They recognized her but did not know who she was.

Department of Mental Health outreach workers were called, and then shelter outreach workers; all recognized our patient but knew nothing about her. The following day the unidentified white homeless female, who had denied suicidality, was discharged.

Not surprisingly, she returned to the ER, and on my next ER shift a couple of weeks later, she was again in a holding room.

Only this time she had a name—and a medical-record number, a history, and a desperate sister. Since I'd last seen her, she had been hospitalized at a local hospital that now refused to readmit her because it was not granted the commitment it had requested last time she was there. Her sister said she was a “perfect lady” when following a treatment regimen, in stark contrast to the threatening, fire-setting woman she became when ill. The sister was trying to pursue guardianship but needed a doctor's corroboration. She had never heard of the National Alliance on Mental Illness (NAMI) or the Program for Assertive Community Treatment (PACT).

The now-identified homeless woman waited an entire weekend in our emergency room. This is not, I am well aware, an uncommon situation. Yet the juxtapositioning of these two visits to the ER and the tragedy of an ER visit that might well have been longer than her last hospitalization started gnawing at me.

How, I wondered, could as vulnerable and ill a person as this woman be left so completely out of our mental health system? Who exactly was our system for, if not this “perfect lady”?

I pushed hard for admission. I told her sister about resources such as NAMI and PACT and encouraged her initial efforts at pursuing guardianship.

But what, I had to wonder, was her actual chance of becoming more healthy as a result of this particular encounter with the mental health system? It depended critically on the persistence of particular individuals: after my shift ended the ER residents and staff continued to push for her to be admitted, and an inpatient attending was willing to take administrative heat about getting her a hospital stay that was more than three days long. She was also fortunate that she had a sister able to follow through on the hard work of gaining a piece of the resource-limited pie.

What we have to offer people such as this woman is not, in fact, a system. Successful treatment that is so dependent on the above-and-beyond work of dedicated individuals is not a solution. It is, instead, a personal means of addressing a very public problem; there is nothing in such an intervention that is replicable. Dedicated, caring people are without a doubt an essential ingredient; they are not, however, sufficient to substitute for a reformed system of care in which this woman could begin to get the care she needs.

In the absence of such a structure, I felt only frustration. If her recent history is any guide, my patient's situation was anything but promising. Even while discussing guardianship and PACT with my patient's sister, I knew that it was far more likely that the now-identified “homeless white female,” after more than 60 hours in a locked holding room, would be admitted only briefly, if at all.

Luckily for me, if not for her, I'll likely have the continuity of getting to see her again, with the homeless outreach team on its weekly walking rounds of the streets of Boston. ▪