McInnis House Provides End-Of-Life Care For The Undocumented And Homeless

Kervin Alleyne, 67, receives end-of-life care at the Barbara McInnis House in Boston, which has 100 beds for homeless and undocumented individuals. He says it’s “one of the best places that a person could ever be.” (Gabrielle Emanuel/WBUR)

Kervin Alleyne, 67, receives end-of-life care at the Barbara McInnis House in Boston, which has 100 beds for homeless and undocumented individuals. He says it’s “one of the best places that a person could ever be.” (Gabrielle Emanuel/WBUR)

The roughly 160,000 undocumented immigrants in Massachusetts do not have access to most public health insurance programs. Some doctors and nurses in Boston have noticed this can pose particular challenges at the end of life, where the undocumented do not have access to nursing facilities or hospice care.

Some health care providers are stepping in to help these undocumented and dying individuals.

‘This Place Is Special’

“How’s your breathing been feeling?” the nurse asks. “Take a deep breath. Has the pain gotten any better?”

“Yes, I tolerate it better,” Kervin Alleyne says, reassuring his nurse that the bone pain he feels is manageable.

Alleyne is dying of metastatic prostate cancer, but he is not one to complain.

He looks around the room at the three other hospital beds, and then out the window to the concrete and traffic of Boston’s South End.

“One of the best places that a person could ever be,” he says. “This place is great. This place is special. Trust me. Trust me.”

Before arriving at this special place, Alleyne was staying in a homeless shelter.

But for the past year he’s been at the Barbara McInnis House. It has over 100 medical beds for homeless individuals.

“We help individuals who are too sick to be in shelters or on the streets but not sick enough to actually warrant a medical bed in a hospital,” explains Denise De Las Nueces, the McInnis House medical director.

Usually homeless patients are discharged after about a dozen days — when they are healthy enough to go back to the streets.

But what about homeless patients who are dying? Continue reading

Why Some Bostonians Refuse Shelter In The Dead Of Winter, And How They Survive

Nelson Bennett stocks the Pine Street Inn's outreach van with food and supplies. (Courtesy Rick Friedman)

Nelson Bennett stocks the Pine Street Inn’s outreach van with food and supplies. (Courtesy Rick Friedman)

A van crawls through the streets of downtown Boston, pausing at the intricate iron entrance to a city landmark or a doorway carved in stone. By day, these openings are passages to power and wealth. At night, they are coveted shelters from wind, sleet or snow. People inside the van know this. Their carefully trained eyes scan the shadows of every building, stairway or bench, watching for hints of life.

On Winter Street, at the end of a brick alley, there’s a flicker of movement. The van pulls over and a figure in a light coat emerges.

“Is that you James?” asks a man with a reassuring, deep voice who has stepped out of the van. “You going in tonight?”

What Happens To The Body Of A Person Who Sleeps Outside In Extreme Cold?

Dr. Jim O’Connell, with Boston Health Care for the Homeless Program, explains:

When a person gets cold, their body shuts down blood going to the skin to preserve warmth near the heart. When hands and feet don’t have enough blood they may develop frostbite.

With frostbite, hands, feet, ears and noses can swell and blister. The skin turns black and necrotic. In cases of severe frostbite, dead tissue will fall off or autoamputate. Some patients are left with a disfigured toe or finger, some lose the tip or whole digit.

In the last two weeks in Boston, a homeless man who sleeps on the street lost one leg below the knee as well as part of the other foot to frostbite. Another man will need to have one of his legs amputated below the knee.

O’Connell explains the body’s reaction to cold in depth here.

Nelson Bennett knows James. He sees this young man often as Bennett circles downtown Boston in Pine Street Inn’s outreach van. It’s packed with blankets, hats, gloves, underwear, socks and sandwiches. Large insulated containers keep hot water handy for instant soup, oatmeal and hot chocolate.

“It always helps, especially in these conditions, to get some warm liquid into your body,” Bennett says.

Bennett and his crew are also out every night trying to persuade people who plan to sleep on the street to spend the night in a shelter instead.

Now, with the temperature at 15 degrees and dropping, Bennett wants to know, will James come in?

No, James says. His girlfriend was assaulted at one of the shelters and won’t go back, so he’s staying out with her. James stands next to a pile of ripped boxes from which he’s pulling pieces to build their bed. It will be three layers of cardboard pushed up against a glass office front with a short wall around the sides.

“I kind of go a little overboard,” James says, laughing. “I don’t want any of the rodents and whatnot getting in.”

James explains he collects new pieces of cardboard every night and throws them away in the morning.

“Once you get in this situation, it’s like impossible” to get a job and get back into housing, James explains. “I have my own issues up here,” he adds, tapping his head. “I’ve had a lot happen, but I don’t want to deal with it so…”

Continue reading

Risks Of Living On Street In Bitter Cold: When Not To Walk On By

Victoria Morris, 28, panhandles in Portland, Maine, where the temperature at dusk was 7 degrees Fahrenheit that early January evening. Morris, who is homeless, decided to seek shelter when she could no longer feel her toes.  (AP Photo/Robert F. Bukaty)

Victoria Morris, 28, panhandles in Portland, Maine, where the temperature at dusk was 7 degrees Fahrenheit that early January evening. Morris, who is homeless, decided to seek shelter when she could no longer feel her toes. (AP Photo/Robert F. Bukaty)

By Bill Mitchell
Guest contributor

With record cold temperatures closing schools and crippling transit around the country, one population remains especially exposed: people living outside.

Every night in Boston, a van from the Pine Street Inn searches for people at risk for frostbite and hypothermia on the city’s streets. Two nights a week, the van team includes Jim O’Connell, M.D., who helped found the Boston Health Care for the Homeless Program in 1985 and now serves as its president. In this edited Q&A, he addresses the medical risks that extreme cold presents to people living without shelter – and what passersby can do to help.

What have you learned about the impact of frigid temperatures on people who live on the street?

After four years of medical school and three years of residency, I was struck – in this job – by how little I knew about frostbite, hypothermia and related issues. I was uniquely unprepared to know how to handle the complexities of these medical problems.

Often people wake up to find that a finger or a toe has fallen off in bed.

When I started to learn about the concept of hypothermia, I discovered that Hannibal lost 50 percent of his Army crossing the Alps in 218 B.C. In the War of 1812, Napoleon lost 50,000 troops to hypothermia during their retreat from Moscow. And 10 percent of U.S. casualties during the Korean War were related to the cold. Interestingly, most of the literature about weather-related medical issues comes out of the military and from those crazy mountain climbers. Exposure to the elements is a fundamental part of wilderness literature, but not prominent in everyday medical literature.

What happens to the body during hypothermia?

Only about 33 to 40 percent of hypothermia cases are related to exposure to weather. Most cases involve an infection that causes the body to lower its temperature or a reaction to medication or use of drugs or alcohol.

The worst cases of weather-related hypothermia we see in our program are not during bitterly cold periods but in the shoulder season between fall and winter. The temperature might be in the 40s during the daytime and people on the street feel comfortable.  But when the temperature plummets into the 20s at night, those who have fallen asleep outside can unwittingly experience extreme hypothermia, especially if they have been drinking alcohol or using drugs, or if their clothing is wet from rain or the ground.

On a warm day, your body cools down by opening blood flow to skin by sweating. The opposite happens in the cold. The body shuts down blood going to the surface of your skin in order to preserve warmth closer to the heart.  This can leave the extremities, particularly the hands and feet, with insufficient blood flow to withstand the cold temperatures.

What is autoamputation?

Each year at our medical respite facility, the Barbara McInnis House, we care for between 10 and 15 people suffering from frostbite that threatens digits and limbs. Hands and feet and tips of noses can swell and develop blisters as if they’d been burned.  Bloody blisters indicate deep tissue damage and more severe frostbite.  Over the course of two to four weeks, the skin turns black and necrotic.

Because we don’t know how much viable tissue, if any, is below these blackened digits, surgery is not usually done and we are left to watch and wait for one to three months — with considerable horror to our patients and our staff — for the fingers and toes to autoamputate (a spontaneous detachment of an appendage from the body). Continue reading

Study Suggests One-Third Of Homeless in U.S. Are Obese

(Deadly Sirius/flickr)

The so-called “hunger-obesity paradox” is one of the many sad truths of urban poverty. Though the poor in general and the homeless in particular are often perceived to be malnourished and underweight, it turns out that obesity is equally pervasive — no matter where you live.

In a new study, researchers at Oxford University and Harvard Medical School found that “obesity is just as common among the homeless as it is among the general non-homeless population.” Here’s the news release:

The study, to be published in a forthcoming issue of the Journal of Urban Health, suggests this could be because cheap foods that are instantly satisfying often contain a high level of fats and sugars. Another reason could be that bodies experiencing chronic food shortages adapt by storing fat reserves.

Researchers examined the body mass index (BMI) data of 5,632 homeless men and women in Boston, and found that nearly one-third of them were obese. They used the medical electronic records at 80 hospital and shelter sites for the homeless in Boston, using data from the Boston Health Care for the Homeless Program– one of the largest adult homeless study populations reported to date. They found that just 1.6% of the homeless in this sample could be classed as ‘underweight’. Morbid obesity – where people are 50%-100% above their ideal body weight – was three times more common with 5.6% of homeless adults classed as morbidly obese. Continue reading

Treating Homeless Women In Boston: Six Questions For Dr. Roseanna Means

Dr. Roseanna Means provides free care for homeless women in Boston

About 99% of homeless women in Boston have been beaten or raped, so providing them with medical care requires a good deal of compassion and a slightly unorthodox approach. Dr. Roseanna Means started the nonprofit, Women of Means, in 1999, when she realized that help for the homeless was primarily geared toward men and overlooked the specific medical needs of women. The organization, which provides free medical care for 2,500 homeless women in 8 Boston-area shelters on the city’s streets, relies on a network of 20 volunteer physicians and six paid nurses. Earlier this month, Dr. Means was presented with a Community Health Leaders Award for her work by the Robert Wood Johnson Foundation. I spoke with her about the growing population of homeless women who are over 70 and why she often begins a patient’s treatment with a foot massage.

Q: How does a pedicure constitute medical care?

A: There is so much trauma among these women, they’ve been beaten up and gang-raped and abused, so if you take the traditional approach, and put a blood pressure cuff on them, it’s like another assault. I just sit on the floor, put their feet in my lap, shave their callouses and do a foot massage. I humble myself to them.

So many people ask, “Why don’t you just charge Medicaid for all your visits?” That’s not our model — there’s no billing code for some of the stuff we do. Continue reading