A disclaimer: To preserve confidentiality, this patient’s name has been changed, and “she” is a composite of several people,. The incidents affirmed here are otherwise factual as witnessed directly by the author. This article will be followed up at a later date with an examination of the historical decisions regarding psychiatric care that made this patient’s situation both common and immutable.

I know a homeless woman who is regularly thrown out of the shelter system for her incessant smoking. Or so she claims – only God knows the truth. She’s also quite a bit psychotic but I believe the ejected-for-smoking part. What happens to her after she goes, and she’s out on the street, sick as she is? Read on.

A passerby calls 911. We paramedics have gotten to know her, and we all know her well. She has made a procession among all of the emergency rooms in the city, as evidenced by the fact that wherever we go, the staff also knows her as well. Let’s call her Evangeline. She weighs over four hundred pounds – a lot of the reason why the smoking is the extreme issue it is. Most smokers in homeless shelters will walk down and line up to smoke on the street (itself a major friction as the locals bitterly complain of a conga line of homeless people smoking). Evangeline mostly cannot make the walk.

Caring for herself has never been a possibility: she is psychotic and too obese for any imaginable employment. Any day now she will come apart with pulmonary disease from incessant smoking. Just being so obese brings a form of pulmonary disease. One of the Emergency Department (ED) doctors wanted her to be on a CPAP machine, but had to be reminded that for her to have an electric breathing-assist device, she’d need an electric outlet, and for that she’d need a place to live, one that does not throw her out for smoking. So she practically lives in emergency rooms.

Turn your eye from the page for a moment and imagine life for a homeless person this sick. How is she supposed to get her medication? She also has high blood pressure, and soon will have type-two diabetes on top of the emphysema she is due. Can anyone expect her psychosis will be improved by sleeping out on the street? Her terrifying living situation can even induce mental illness in the otherwise sane. As in being “driven crazy.” I’ve seen her where she’s laughing and joking one minute, then the next she suddenly start bawling about how her family cast her out, the shelters cast her out, the emergency departments cast her out, she’s nothing but a big problem for every person she ever meets, everybody hates her, it would be better if she were dead, what is she on this goddamn planet for? Imagine lying to her face, telling her it’s all not true, while putting in the energy it takes to make her believe it, after the heavy-lifting project required to just move her (often two EMS units are needed). And then, in the time it takes to go from one traffic light to another, she switches back to her jolly joking charm. So, we can add in that she is probably bipolar as the cherry on top of her misfortune sundae.

Evangeline has: “integrated into her survival strategy trips to the ED for food and shelter” (and I talked this concept out with more than one of my colleagues to reach this definition). Sometimes, yes, she just goes to the ED for lunch. But mostly, she goes to the ED because her situation is pitiful, and this makes her sick. Sick in body, in mind, in soul. Her sickness is a thicket. Where mental illness, illness-illness and her life-situation begins, and the other ends, is not knowable.

She’s been arrested a boat-load of times. She’s been thrown out of the ED for stealing food off other patient’s plates. You get the feeling that a century ago some priests and nuns would smile gently at her acting out, not call the cops on her (she can have volatile outbursts), find some menial work to put her to, feed her when she was hungry, and save everyone the millions. With the additional benefit that they would not be hurting her worse. The prime directive of medicine is, incidentally, “First do no harm“. Suppose a church did try to apply their doctrinal mercy on her? But no, there’s the smoking, illegal everywhere in New York City, the signs prominently posted right up with the stained glass lessons from the Bible. Also, the church’s lawyers would have them mitigate their liability, and for good reason: the woman is a walking (when she’s able) liability Beano bomb.

This over-watching threat of liability is why nobody can tell her to go away and get a sandwich (forgetting all the times she is legitimately ill). All clinicians have thus been turned into liability bomb disarmers. That this evil-spirit definition of liability has fundamentally changed emergency care, over the time-horizon of what I’ve seen in my career, is a topic for another day.

Throwing her out of the ED is also fraught with liability risk. Any doctor who does it will briefly be a “no-guff-taken” hero, at least until risk management finds out about it. But what will happen next, with her lumbering back and forth outside the hospital, bawling and gasping? You got it, a passerby calls 911, rinse and repeat at the next ED.

Add in my intuition that no small part of all of this is the primal human rule that no person will submit to being a living ghost: it is as true for adults as for children that even bad attention is better than none. She has undeniable power to make us pay her attention, and I’ve “caught” her savoring her power more than once (maybe her only power). The irony of our system is that she demands the attention of the very people who most need to ration it by importance; the triage of the attentions of emergency clinicians.

All of this constant hospitalization we tax-payers pay for, and exquisitely: a paramedic ambulance costs a thousand dollars on average, a visit to an ED costs $1,500, an overnight stay in a regular room is $10,000. She has wound up in intensive care more than once, at an additional $4,000 per day. It would be cheaper to get her a suite at the Plaza where they would treat her smoking as an eccentricity (and more effective, assuming the room comes with an electrical outlet). It is certain that she has cost taxpayers hundreds of thousands of dollars (and millions is a possibility). And, she is but one patient. Also, this math cannot factor the cost to the poor schnook who calls 911 for a “real” medical emergency and finds there are no resources available, because we are functioning as a perennial human moving company.

But that’s not even the worst of it. If we were fixing her, it could be evidence of our ethos that we won’t compromise with any individual’s life, no matter the cost, and we’d learn how to do it better for the Evangelines of the future. But in her case, our system is eye-wateringly expensive and completely ineffectual (anti-effectual, really). And it will allow no adaptation, no learning.

All of us have the authority to use our medical judgement to sedate her, and place a breathing tube in her lungs, if medically justified (the only way to shut her up, it’s been joked). But, bureaucratically, her many issues require slavishly continuing the way we do without any possibility for judgement. The same as always and before, everyone following the rules while knowing the futility, as if the rules were laws of orbital mechanics. But the loop is really a wheel. It is really propelled by the hamster of law. Except this hamster has the power to take away any dissenters’ professional credentials, or to lawsuit-hound them out of their own house and home.

You and I and all the rest of the taxpayers will pay for this hamster to go until a solution is found, or until she dies (which is more likely). Next time you write a tax return check know that it will not even cover one week of just this one person’s situation. Next year will bring the same running wheel. Evangeline is also not the only “Evangeline-like patient” I know. Far from it. I could tell of patients that call 911 every day, some several times a day.

If there is anyone I ever met who needs a safety net, it’s her. And the hamster pulls it out from under her, at massive expense to me and you, for her own good.

After all of that, of course, nobody can get her to quit smoking.

• About the Author

About Eugene Darden Nicholas

Eugene Darden (Ed) Nicholas is from Flushing Queens, where he grew up sheltered from the hard world, learning the true things after graduating college and becoming a paramedic in Harlem. School continues to inform and entertain in all its true, Shakespearean glory. It's a lot of fun, really. In that career, dozens of people walk the earth now who would not be otherwise. (The number depends on how literally or figuratively you choose to add). He added a beloved wife to his little family, which is healthy. He is also well blessed in friends and colleagues.