Are Hospitals Helping the Homeless?

A few times a year, for eight consecutive weeks, Sean Cononie teaches a first-responder and emergency medical treatment class. The students learn CPR and what to do if someone has a seizure or goes into cardiac arrest. They learn basic ambulance training, like how to operate an automated external defibrillator and how to clean a wound that might be infected with Methicillin-resistant Staphylococcus aureus, better known as the "superbug" MRSA.

The class wouldn't be so unusual — except that the participants learning mouth-to-mouth are homeless. They meet in Hollywood at the Voice Homeless Shelter, which Cononie runs. The reason for the class is twofold. If something goes wrong on the streets, these homeless people will be nearby, so it only makes sense that they know what to do as first responders.

The second reason is more disturbing. Many of these homeless people say they need to learn emergency medical training because they aren't receiving adequate treatment in the county's public emergency rooms. They claim ER personnel at Broward General Medical Center in Fort Lauderdale and Memorial Regional Hospital in Hollywood rush homeless patients through treatment, discharge them without treating them properly, and are careless and rude in their dealings with them. Some hospital employees even ask homeless patients if they will leave in return for food, the homeless folks say.

Cononie, who is 43, says that in his professional opinion, the staff at Memorial Regional Hospital generally go out of their way to treat the homeless, "and they have one of the best indigent health care programs in America" — but individual doctors and nurses at Memorial do neglect homeless patients. They ignore the seriousness of some medical problems that afflict homeless people, he says, and they fail the public by disregarding the welfare of some of the most desperate members of our society.

Health care for the indigent in Broward County is generally exceptional, Cononie continues. Often, patients are given expensive tests and procedures such as MRIs without having to pay, he says, and they can receive brand-name prescriptions for less than $10.

"This isn't a problem with the institutions, really. The hospital policies are good. This is a problem with individuals who just don't want to deal with homeless people and all the things that go along with them."

Cononie is reluctant to discuss such complaints in detail, he says, because as an advocate for the homeless, he must continue to deal with some of the same county health-care providers every day. Some of them are burned out, he surmises. "That's human nature. But we have to have reality checks. No matter how burned out anyone becomes, they have to treat everyone. Sometimes, they just need to be reminded to have a little compassion."

This is not a problem peculiar to South Florida, Cononie notes. "Everywhere across the country, you will get burnt-out ER workers and hospital workers who feel in their heart that the homeless did this to themselves. I have made bad decisions in the past and maybe not treated everyone the same — but when it comes to health care, we must do our best."

It is also a problem that the homeless themselves may exacerbate by crying wolf. Hospital employees sometimes must deal with homeless people who are tired of sleeping on the streets, people who know that with one call to 911 and a complaint of chest pains, an ambulance will likely whisk them away to a hospital. There, for a few days, a homeless person can clean up, be fed, and sleep in a real bed with clean sheets.

Other homeless people may go to hospitals seeking drugs, which in turn can make doctors and nurses cynical, assuming that apparent indigents just want narcotics so they can get high. "The homeless know the game, and the providers know what their game is," Cononie says. "I have seen some people being released with Motrin," an over-the-counter pain reliever, "when they just broke their arm three hours ago."

As a matter of policy, Broward General will not decline to treat anyone for any reason, spokeswoman Michelle Cuello says. "We're paid for by the state, so our policy is to treat everyone the way they deserve to be treated — with care. Our doctors and nurses deal with things that are much worse than urine or feces, and they treat patients the right way."

Broward General takes steps to ensure no patient is discharged before having a chance to see a doctor and receive proper diagnosis and care, Cuello says. To do any less — to discriminate in care giving — would be shameful, she says.

Michael Allen, 64, used to be a construction worker. When he showed up at the Voice Homeless Shelter a few weeks ago, he was in rough shape. He'd been discharged from a local emergency room despite his having a smashed collarbone with a visible separation wide enough to poke a finger through. Worse, though, was Allen's abdominal hernia: A tear in the muscle wall above his waist had opened so far that his intestines were seeping through it.

A slender, quiet man, Allen lifted his shirt for a recent visitor to show how bad the condition had become. Where normally there might be a thin layer of tissue or fat, his digestive tract bulged out, moving and burbling as he digested his breakfast. When he sat, he winced uncomfortably. He said he had already been to a local hospital, where doctors told him they could not operate on his hernia because it wasn't an emergency.

"They told me it wasn't serious enough yet. They wouldn't help me. They gave me some food, but they weren't nice at all."

Hernias such as Allen's typically are deemed emergencies when the distended intestines become strangulated, which in turn can cause a gangrenous bowel, or when the hernia becomes septic, which can be fatal.

"They told me to come back when it got worse," Allen said. But "when this gets worse, I'll be dead."

Another man at the Voice Homeless Shelter said he was discharged from a local hospital with an abscess on his buttocks that was cleaned but not swabbed or cultured to determine whether MRSA was present.

New protocols from the Centers for Disease Control require doctors to test all infected wounds for MRSA, which resists all but a few strong antibiotics. Left untreated, MRSA can rapidly eat through human tissue and prove fatal in just a few days. A small wound can become a condition requiring major surgery overnight. For the uninsured, the cost to taxpayers blossoms along with the infection; a condition that could have been treated immediately and relatively inexpensively early on can quickly become one that costs hundreds of thousands of dollars.

Cononie, who serves on the state's MRSA task force, says some doctors blame ER workers for spreading the infection by not culturing wounds appropriately and not changing latex gloves with each patient; by not changing gloves, a care provider protects himself while putting patients at risk. If the patient is homeless, he might be sent to a shelter, where he is likely to pass the infection on to others. The Voice Homeless Shelter is full of MRSA, Cononie says. He's had it three times himself, he says, even though he's diligent about washing his hands.

MRSA doesn't just come from hospitals anymore, Memorial Regional spokeswoman Kerning Baldwin says. "It's a community problem." Memorial is seeing an increasing number of MRSA cases in people who have not been to a hospital or a homeless shelter, she notes. Baldwin said she could not comment on any specific instances in which homeless people allege they were mistreated at her hospital other than to say that its mission is to treat every patient without regard to his ability to pay. The law stipulates no less, she added, "and we follow those laws to the best of our ability."

Meanwhile, the Voice Homeless Shelter recently bought an ambulance so its workers can go out on the streets and administer care themselves. This way, Cononie says, he can run tests and have blood work done without having to send his clients to an emergency room.

And Cononie says he's arranged for Allen, the hernia patient, to have surgery before it's too late.

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Michael J. Mooney