By Anthony McClafferty
At Manna Meals in the basement of St. Peter’s Episcopal Church in Corktown, medical students from Street Medicine Detroit (SMD) carry backpacks and boxes of medical supplies as they pass through the cafeteria. A man in the hallway receives his meal and asks if there’s a psychiatric nurse among the group, a clue as to how one might end up at Manna Meals.
Chairs are pulled from the eating area and set up in a dusty backroom that houses a tuneless piano, some donated clothes, and at the moment a clinic. The students are dressed in street clothes, the stethoscopes around their necks the only outward sign of their medical role here. Over the next hour and a half, students get to work interviewing patients, checking vital signs, and presenting patients to Nurse Practitioner Dean Carpenter for diagnosis and treatment.
Dean provides primary health care services at the Neighborhood Service Organization’s (NSO) Tumaini Center. The center, located off of MLK Boulevard on 3rd Street in Detroit’s Cass Corridor, provides respite care for individuals experiencing homelessness.
“There’s a certain population who won’t or can’t seek our services,” Dean said. “Maybe they are mentally ill or the medical community has disenfranchised them in the past.”
In December 2011, Street Medicine Detroit founder and then first-year medical student Jonathan Wong approached Carpenter with an idea to make medical services available to Detroit’s nearly 20,000-person homeless population. Jonathan was inspired by the growing practice of street medicine. His initiative found a natural home at NSO as Dean saw a chance to increase his reach. Street Medicine Detroit officially organized in May 2012.
Many of SMD’s patients have had negative experiences with doctors in the past, and medical encounters are often vulnerable situations. Visiting a doctor can be an uncomfortable experience for the average person, but for someone on the margins of society, it’s prohibitive. Additionally, homeless individuals face structural challenges to accessing healthcare.
Medicaid requires a permanent address to verify state residency. Without insurance, emergency departments are overused in order to receive primary care. Lack of reliable public transportation in Detroit also makes it difficult to attend clinic appointments, especially during the winter months. By bringing health services directly to patients, SMD aims to remove most of these barriers with the ultimate goal of connecting patients to consistent primary care.
“If we did our jobs perfectly, we wouldn’t have any patients left to see. They would all have primary care providers,” Street Leader, Samantha Terranella said.
SMD’s mission is ambitious, but Street Medicine Detroit is not without its partners, many of which have a long track record of homeless outreach. Working alongside students, are NSO employees Philip Ramsey and Lydia Atkins, familiar faces around the homeless community. The two often triage patients for SMD, establishing the initial contact and trust necessary for a successful intervention. Carpenter stresses that SMD is also a teaching environment. He’s looking to instill confidence in his students’ interviewing abilities, so that they are comfortable treating any type of patient.
Along with the medical students, Carpenter brings nursing students on street runs. Joseph Kalejaye, a nurse practitioner student from Michigan State University has accompanied SMD on 15 runs, and his experience shows.
He counsels a patient on the best way to control her asthma, recommending that she returns to see him if she ever finds herself without her inhaler. SMD will provide her with one free of charge.
After speaking with the patient, Joseph admits to having been apprehensive about his placement with NSO and working on street runs. He now counts the experience as a unique and useful component of his education.
“This was my first experience around the homeless, and this work, for me, helped remove the stereotype surrounding homelessness,” he said. “I realized that many people are here due to situations beyond themselves. Sometimes there is a tendency to blame people for ending up here, but that’s not the reality of homelessness.”
With his last nursing rotation wrapping up and looking toward his future career in primary care, Kalejaye says that his experience with Street Medicine will inform his future decisions as a nurse practitioner.
“With the homeless community, you have to prescribe cost-effective treatments that patients will follow. It doesn’t do the patient any good to prescribe something that the he or she can’t afford or doesn’t want to take. This applies to all patients. We should be practicing cost-effective medicine everywhere.”
Wayne State University’s Department of Psychiatry and Behavioral Neurosciences has studied the frequent use of emergency departments by the homeless, finding that 66% of those surveyed had made 3 or more emergency department visits each year.
It’s not hard to understand why. Life on the street and in shelters is not conducive to managing a chronic disease, and health problems can quickly escalate, often resulting in visits to the emergency department. The study puts the number around $1,600 per day for frequent users from the homeless population at Detroit Receiving Hospital. Proper primary care management can help us avoid these expenditures. As the students pack their equipment and supplies in a van, a man stumbles up asking for his pills. He’s late and has missed the clinic. He admits, halfway between an apology and a weather report, that he’s been drinking. From the back of the van, Carpenter stretches forward for a better look, trying to place the man.
“He’s actually one of our success stories,” he tells the doubtful students, “well, partial success story.” As he digs through his backpack of medicine, he describes the patient’s story: how an NSO employee found him living in Savage Park and how the man would often experience intense seizures requiring him to go to the emergency room.
“In the ER, they would give him his Dilantin, but once he left he’d go back to drinking heavily,” says Dean “Once the pills ran out and the seizures came back, he was back in the ER.” With Mr. Ramsey’s help, Street Medicine Detroit intervened. “Now he comes to us to get his anti-seizure medication, like clockwork. He seeks us out. No more ER visits.”