A young woman stands in the freezing cold outside an urban Baltimore hospital. The woman, covered only by a thin hospital gown, moans incoherently at the man capturing her suffering on cellphone video. As seen on the now-viral video, she’d been left there by security personnel employed by the supposed place of healing just a few yards away. It hurts to watch.

Mass media outlets are appalled. Where‘s the empathy? Another failure of our “broken healthcare system” and a screaming example of inequality on every level (she’s poor, female, African-American, and mentally ill). Case closed in the court of public opinion.

But those of us on the front lines working in our nation’s safety net hospitals don’t get to talk about the details of cases like this due to patient privacy laws. So let’s speak using the hypothetical “what if?”

What if the staff of this inner city hospital in a heavily impoverished area with a high crime rate, high drug abuse rate, high mental illness rate, and high rate of homelessness needed to deal with “frequent fliers” (patients who repeatedly use hospitals to satisfy basic needs for food, shelter, medicine, or other attention) on a daily basis?

What if many of patients at this institution had long complicated psychiatric and social histories, and as such are well known to multiple hospitals in the area?

What if this poor woman had suffered since childhood with mental illness and developmental delay, making it nearly impossible for her to function in society without help? What if there were a history of belligerence and violence towards healthcare staff and nonadherence with care plans, either for admission to the hospital or discharge to cold shelters? What if the ER, already quite busy trying to handle numerous other emergencies, determined she did not meet criteria to be admitted?

A lot of armchair psychiatrists are screaming, “It’s clear this woman should be in the hospital. She’s crazy and not competent to care for herself,” forgetting that mental status can wax and wane very quickly, and while being evaluated one’s competency is judged during a discrete time period by professionals (as opposed to a few minutes of cellphone video taken on the street). What if it’s also against the law to hold a patient against their will unless they demonstrate during the evaluation period that they are a danger to themselves or others?

What if this woman did not meet those criteria during evaluation, was offered a transfer to a shelter and refused, had burned her bridges at other shelters, and burned her bridges with family and friends?

What if there was violence on the part of the patient, with altercations and refusal to follow commands in the hospital after discharge, ultimately leading to an escort by multiple security personnel due to the strength and potential danger she posed to the staff? Let’s hypothetically imagine that this is what happened. Should she have been thrown out into the cold in nothing but a gown?

What if we added another “what if”…

What if she was given all her clothes and told to dress but refused to do so. What would you say then? Would you say, “Could it be her mental illness? Or could it be that she made a choice? Could it be that the security guards made a mistake, having dealt with so much belligerence and so many difficult patients?”

We don’t know. But here’s something that isn’t hypothetical: this case is a picture of disaster from start to finish in a city struggling with poverty, with difficult race relations, with inequity, with mental illness, with homelessness, with substance abuse. We shoulder our institutions of healthcare with the burden of solving the upstream societal problems that our pathetic, short-sighted political leaders have lacked the courage and human decency to address. We medicalize our social problems in the US, and then scream accusations at our frontline healthcare workers who are tasked with doing the impossible despite burnout, physical risk, daily humiliation and constant devaluation.

We look to our hospitals, to our doctors, to our nurses, to our respiratory therapists, to our social workers, to our psychiatrists, to our case managers, to our discharge planners, to solve the problems that we’ve been collectively too craven to solve ourselves. Then when a tragedy like this is documented on video (and this is just the tip of the iceberg), we ignore our failure to manage the root cause of the problem, instead pointing at the nearest scapegoat. People are outraged at the emergency department. Yeah, you should be outraged. You should be mad at the emergency department for failing in the face of impossible odds. But you should be furious at the larger system that failed this woman and hundreds of thousands of others like her who suffer daily.

What if we as a society addressed the upstream causes of homelessness, poverty, inequality, and chronic disease? What if we funded mental health care and provided safe housing and support for those in need? What if we shifted some of the 3 trillion dollars now wasted on ineffective healthcare towards that very end?

What if?

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Zubin Damania:                   Hey, Z-Pac. It’s your boy, ZDoggMD. Check it out. I’m live and direct from Z-office today, and I want to talk about a story that’s been going around the news all over the place. Multiple, multiple, multiple people have sent this to me over the last couple days. I watched this video of this young woman being discharged forcibly, it appeared, from the University of Maryland Midtown campus in Baltimore in what appears to be in the nighttime in very cold temperatures, and a bystander who happened to be a psychotherapist in town videotaped the proceedings. What you see in the video is a young African-American woman in a hospital gown shuffling around confused, disoriented, moaning, clearly she’s not dressed for the weather. There were, I think, three or so security guards, I didn’t count them exactly, but several security guards that dropped her off and then walked away and had an interaction with the gentleman filming and walked back in.

Zubin Damania:                   This clip has since gone viral. It’s pretty clear to understand why it might go viral. What you see on this video is a side of a story where you see a young black woman who’s clearly mentally ill, who’s clearly doesn’t have the capacity to be out on the street, in freezing cold temperatures in a hospital gown, sent away from a hospital, which is supposed to be a place of protection and healing and safety. Right? The whole time there’s editorial going on on the video, and it appears that security personnel have escorted this woman out and left her there on the street in this gown. Now, when we see a video like this, my first reaction, I think many people’s first reaction unless you’re, frankly, unless you know something else or you’re a racist or you’re just heartless, is, you see this, and you employ something we like to call empathy. You put yourself in this woman’s shoes and immediately feel the suffering of being put out on the street in freezing cold temperature.

Zubin Damania:                   The response is pain, outrage, indignation, anger. All of these emotions will be your first draft for most people, especially, but not limited to, non-medical people. Patients, laypeople will see this and will be furious. Honestly, it is 100% appropriate. When I saw this video, I was so angry that this could happen, and I thought, I’ve seen these cases of patient dumping where patients are dumped out on the street. We call it, in the hospital world, we call it dispo to street. Disposition to street. We send them out of the hospital to the street, because they don’t have a place to live, they don’t have followup, they don’t want followup, whatever it is. Not our problem anymore. That does occur, but in this case, someone who’s clearly mentally ill in freezing cold temperature, of course, has provoked national outrage.

Zubin Damania:                   Multiple news outlets have reported on this, and it is almost exclusively a story of, what are these evil devils at the University of Maryland Midtown campus, which used to be, apparently, Maryland General, but was acquired by University of Maryland in sort of a satellite campus. Mostly outpatient focus, from what I understand from people who have told me. Now, this is a normal human reaction, and this is why the press loves these stories. This is why these stories move action, and this is why people keep talking about empathy as a driver of action. Here’s a question. Is it a driver of good action versus compassion which is love in the face of all suffering? Let’s unpack this story. I’m in a unique position, Z-Pac, thanks to you. We have a tribe here where if something like this happens, I can put out an APB in the morning, which I did, I said, “Guys, in Maryland, tell me what’s really going on here. Give me all sides of this story. I want to hear what’s up, because the press is only going to give us X.”

Zubin Damania:                   The big tragedy of these cases is that healthcare professionals cannot tell their story openly because of HIPAA, because of patient privacy, which is very appropriate, but they cannot say, “Well, this is what happened,” and so as a result, you’re going to get only one side of the story, the story told by the video clip. Do you guys remember the Peter Gallogly case where the young woman was yelling, was yelled at by Dr. Gallogly, who was an emergent care doctor in Florida, and it looked very clear that he was being a jerk and was kicking her out? It then came out later through the police report, which was not a violation of HIPAA, it was a police report, what had actually happened that there was belligerence on the patient’s part, that they had pushed the staff, etc. Didn’t excuse anything, but it changed the context of the story. What’s going on here? Well, I have this unique position of having this tribe of people who work in healthcare.

Zubin Damania:                   I put out a call this morning, “Say, fill me out on the details in a broad sense. We’re not going to violate HIPAA. You just tell me what might be some of the backstory here that might help me, and we’re going to be respectful. The patient’s, I’m not using the patient’s name. I’m not showing her image. The patient’s mother has gone to the press and has already talked about some of this stuff from her angle.” Now, what I, now let’s imagine this. What we see is a woman thrown out on the street, abandoned in freezing cold temperature in a complete failure of compassion. That’s what we see on the tape if you just look at the tape. Now, what could we imagine, and I’m just going to pretend that I might know stuff from people who’ve been on nearby locations to this event? What if this was an inner city hospital in an incredibly impoverished area of Baltimore with a high crime rate, a high drug abuse rate, a high mental illness rate, a high homeless rate?

Zubin Damania:                   What if these hospital staff on a daily basis deal with quote-unquote “frequent fliers,” who are patients who are constantly in and out of the emergency department, who are known to multiple hospitals? What if people from multiple hospitals kind of could fill in some blanks on that, and you could start to get a picture of the potential that our patients at this hospital have long, complicated psychiatric histories, are well known to all the hospitals in the area and transport staff? What if we found out that this poor lady had suffered since she was a child with mental illness, developmental delay, and other things that would make it very hard for her to function in society? What if there was a history of belligerence and violence towards healthcare staff and nonadherence to plans, either for admission or discharge? What if the ER was already quite busy and trying to handle other emergencies, and what if, in this state, this patient refused, say, a transport voucher to a cold shelter or other sort of followup, and what if she did not meet criteria to actually be admitted as an inpatient?

Zubin Damania:                   There are a lot of armchair psychiatrists out there in the comments in particular, in the lay press, that are saying, “it’s clear this woman should be in the hospital. She’s crazy and not competent,” but you have to understand, these things wax and wane very quickly, and when you’re being evaluated, your competency is judged by professionals as to whether you are holdable on a psychiatric hold. It is against the law to hold a patient against their will unless they qualify for a psychiatric hold, and they’re a danger to themselves, a danger to others, they’re gravely disabled. What if this woman did not meet those criteria, was offered a transfer to a shelter, had maybe in theory burned her bridges at other shelters, burned her bridges with her family, who did not want to take her home, and therefore had washed their hands temporarily of her, did not know where she was?

Zubin Damania:                   What if all of this then led to violence on the part of the patient, where there were altercations and inability to follow commands in the actual unit, ultimately leading to a discharge that ended up having to be escorted by multiple security due to the strength and potential danger that this patient posed to the staff? Let’s just hypothetically imagine that this is what had happened. Does this make her being thrown out into the cold in a gown correct? Most people would still say no. Now, what if I added a piece of information? She was given all her clothes and told to dress and refused to do so. What would you say then? Would you say, “Could it be her mental illness, could it be that she made a choice?” We don’t know.

Zubin Damania:                   My point is, now she’s on the street being videotaped. We’re seeing a segment of a story. The other part of the story cannot be told except by me here, because I’m hypotheticalizing, and what if, then, we paint a picture of a disaster from start to finish in a city that is struggling with poverty, with difficult race relations, with inequity, with mental illness, with homelessness, with substance abuse, and what if we throw into the mix the fact that our institutions of healthcare have been shouldered with the burden of taking care of all of society’s problems that our pathetic, useless leaders in Washington, both on a state and a federal level, have not had the courage or the human decency to actually address on a global setting?

Zubin Damania:                   And what happens? They look to our hospitals, to our doctors, to our nurses, to our respiratory therapists, to our social workers, to our psychiatrists, to our case managers, to our discharge planners, to solve the problems that they are too much of cowards, that they are too craven to solve themselves. Then when something like this happens, which is the inevitable outcome of a failure to manage the root cause of the problem, which is mental illness, substance abuse, poverty, injustice, all those things that are now foisted on the people who work in that emergency department, and when something like this happens, what happens? People are outraged at the emergency department. Yeah, you should be outraged. You should be mad at the emergency department. You should be mad at the system that failed this woman and hundreds of thousands of others like her who suffer in our broken non-system.

Zubin Damania:                   Who has abrogated their duty to manage all of this? It’s our leaders, yes, but you know what? I’m going to be honest. It’s all of us. It’s those of us on the front lines. If we don’t stand up and make noise about this without pointing the finger, “Oh, the administrators who run the hospital,” and they apologize because they know this is a PR disaster. I’ve heard from people who know this hospital and they know the struggles that they go through, and there’s pro and con as to how good they are at managing them, but nobody denies that they care about the patients, that they’re overwhelmed, that they’re underfunded, and that they’re in what is effectively a demilitarized zone trying to solve societal issues on a daily basis with minimal resources when people who actually need a hospital bed right then are being displaced by people who are doing what they are incentivized to do, which is try to get shelter or try to get admitted by saying they’re suicidal.

Zubin Damania:                   This is the real outrage behind this story, and this is what nobody is talking about except for frontline healthcare providers, except for people suffering from mental illness. The peanut gallery, the mob, they want to jump on this. The guy who filmed it, he, it turns out he’s kind of an activist for this sort of thing, so it’s great to raise awareness, but it’s not about the heartlessness of the hospital, how he’s spinning it in the press. It’s about the heartlessness of a non-system that allows this to happen. Now, let me read two comments here that particularly stuck with me from people on the ground there. Now, one is from Emm Jater, who I think is a pseudonym. He’s a psychiatrist in Baltimore. Private messaged me and then put a public message out that got 689 likes on the thread that we started. Then the other one is from our zdoggmd.com/forums, where people can create anonymous profiles and leave messages without fear of retribution. We got a bunch of those.

Zubin Damania:                   Here’s what Emm says. “This is Baltimore, Maryland. This hospital is one of the poorest neighborhoods, and many use the ED like a homeless or detox center. The donations are few, and they get tapped very quickly. The homeless know that if they say they’re suicidal or have chest pain, the hospital can’t discharge them. About 60% of suicidal patients aren’t suicidal but need a place to stay because they’re hungry and they’re positive or withdrawing from cocaine, heroin, alcohol. That being said, of course, the patients who really need what a hospital can offer get squeezed out by those who were inappropriately using the ED. If you’ve never worked in an inner city ED, you have absolutely no idea how few resources are available and how no one funds the place. If you’ve never worked … On the contrary, Maryland hospitals have what’s called a ‘global budget,’ so if this lady is admitted within the last 30 days, and the hospital is financially penalized then for readmission. Yes, the state incentivizes hospitals not to readmit patients.” My daughter playing violin over there.

Zubin Damania:                   “Now, no idea if any of this applies to her case, but imagine working there under these conditions. Fund mental health. All this faux outrage about the opioid epidemic and bad mental health outcomes is meaningless unless we get more funding to open beds, provide shelter, treatment, and counseling,” for what I think is a disease. Right? “Bashing this medical center is scapegoating instead of addressing the real problem in our health care system.” Amen, Emm Jeter. That, that, and that’s from someone who works in that system. Here’s another one. TraumaTasha on the forum. This is what TraumaTasha writes. “I’ve worked in an East Coast inner-city level one trauma center. It’s tough. The situation is tough. Unfortunately, we will never hear the other side of the story.” Absolutely true. Right? Because we can’t tell that story, because of HIPAA and because of professionalism. Right? That’s why I’m trying to tell it in a roundabout way. All right?

Zubin Damania:                   “We do not know what led up to this lady’s discharge. Could it have been a ruthless discharge? Possibly, but I doubt it. For those who truly believe this is the case, please spend the day in an inner city ER and help the nurses solve the world’s problems. It is harder than you think. Some patients have burned all their bridges with family, have been kicked out of every shelter, or even more likely, the shelter has no room. What is an ER to do when their 90 beds are full, plus 20 patients on carts in the hallway, which by the way … ” That’s Vegas. That’s Vegas. All right? It’s all mental illness in the hallways. They’re all being boarded, because we have no place to send them. This is the U.S., people. This is the apex of the civilized world, and this is the best we can do for our own people, for our own society? I’m going to keep reading this.

Zubin Damania:                   “Sometimes patients can’t stay until morning just because it’s cold. Tell me how they should have let her stay in the lobby. For all we know, they did, and she abused the opportunity. Tell me how they should have gotten her dressed first. For all we know, they tried, and she became abusive and started accusing them of assaulting her. Tell me how there are always resources for these situations. I promise you there are not.” This is the true outrage of what happened in Baltimore, and now we have some comments. Melissa [Jensen 00:16:50], “Thanks for speaking up for medical professionals who can’t speak up for themselves.”

Zubin Damania:                   Melissa, this happened with the Charlie Gard incident in Great Britain. It happened with the Peter Gallogly incident. It happened in Delnor with the nurse who was taken hostage and raped, and what does the press say? “Nurse unharmed.” This is how they treat the people who take care of all of us, and you know what? We also have stepped back in a kind of inertia where we’re willing to accept this powerlessness. We have a massive voice, and this platform is only a tiny piece of that. Could you imagine just this little platform, we have 2,000 live people watching right now? We have thousands of comments.

Zubin Damania:                   We reach into every, the press comes to me after this and wants to interview me, and I tell them to F off, because I know they’re going to edit it in a way that isn’t going to be useful to get the story out, but each and every one of us has a voice. Each and every one of us can step up and be a part of this solution instead of pointing the finger where the problem isn’t. That’s not the problem. The problem is all of this, and it’s also the failure of our leadership to address it. We have a failure of leadership in this country across the aisle. Democrats, Republicans, Libertarians, I don’t care who you are. You suck at fixing these problems that are not intractable. We can actually make them better.

Zubin Damania:                   All right, let’s read a couple more comments. #SilentNoMore, [DD 00:18:10]. Absolutely, and this is a “Silent No More” case. If there was abusiveness in the hospital requiring security, right? Just got off work in the biggest EMS system in Florida. Narcan. The same guy twice this week, full ALS workup. Says Michael [Poicard 00:18:29]. People don’t want to help themselves. This is part of it, Michael, but I still subscribe to the disease model. Like this poor lady, if you look at her, just let’s forget empathy for a second. Empathy is feeling someone else’s pain. You don’t want to feel this Baltimore patient’s pain. You don’t want to feel Rebecca’s pain. That’s what her mom publicly said her name, her first name, is. You don’t want to feel Rebecca’s pain, because it will cripple you, it will destroy you, and it will make you make stupid decisions and rash short-term decisions like blaming the hospital for this problem.

Zubin Damania:                   The hospital shares culpability, but if you have compassion, which is the desire to show love, unequivocal love in the face of human suffering across the board, it is a bigger love, it is a bigger, wiser response to suffering. You don’t take it as your own, but you see it. You know it’s there. It’s a kind of cognitive empathy. You understand that this woman was probably abused as a child, that suffered in a difficult situation in a hard part of the country to grow up, and if there was racial bias and other inequity there, that adds another element to it, and you throw it all into mental illness, and what do you have? You have incredible human suffering, someone who is on the street in Baltimore in the winter, and it’s 30 degrees outside, and she’s standing in a patient gown because she refused to dress and became abusive with the staff, theoretically. Can you imagine the suffering?

Zubin Damania:                   Forget about her decisions and her capacity. Can you imagine the human suffering? Now, multiply that by 100,000, and that is the mental health crisis in this country. If we sit down, if we don’t do something and make a voice about it and stop blaming and switch to compassion and love, try to figure out how to solve these problems on a grand scale, we are complicit. All right, Z-Pac. My daughter’s going hardcore on the violin, so I’m going to end with a call to action. Hit “Share” on this. Send this to people who shared the Baltimore clip with you and tell them, “Just watch it. It’s just a few minutes. It’s from a doctor who’s talked to other doctors and other nurses and people on the front lines, and get both sides of the story so we can do something to actually make this better for all of us, especially those who are suffering, suffering, suffering the most.”

Zubin Damania:                   Come to the forum. Make your voice heard, zdoggmd.com/forum. Get people to follow this page, and I’m going to end with a quick, we do these little Facebook Ads. That helps fund the show. It’s targeted to you. If you don’t want to watch it, check out now. If you do, if you just sit through for another 15 seconds, it really helps our show. I love you guys. Stay safe, and we out. Thank you, Z-Pac. I love you. We out.

 

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