A 52 year-old homeless man presented to the ED with knee pain after a mechanical fall. X-ray confirmed a depressed, lateral tibial plateau fracture. He was discharged with a knee brace and a referral to orthopedic surgery. Because of continued knee pain, he returned to the same ED two days later and went to a second ED two weeks later. Each time, he was given pain medication and discharged. He never received a call from the orthopedics clinic.
Six weeks post-fracture, police found him in the streets confused, and he was taken to yet another ED. He was diagnosed with schizophrenia and a UTI and discharged with antibiotics and instructions to repeat a calcium level in one week. His calcium level was 13.5 mg/dl. The patient’s sister who lives out of state was called, and she arranged for him to stay at a hotel. She then contacted the National Healthcare for the Homeless, a national network of healthcare advocates who then contacted the Valley Homeless Healthcare Program, a local homeless program. Two staff members visited the patient at the hotel and found him unable to move due to leg pain. They noted marked, left calf swelling and paranoid behavior, and facilitated his transfer to the hospital via ambulance.
Inpatient labs were notable for a calcium of 13.3 mg/dl, PTH 338 pg/ml, and a parathyroid SPECT scan showed a parathyroid adenoma. He was also found to have an occlusive thrombus in the left common femoral to popliteal vein, and started on warfarrin and exonaparin. On hospital day #10, the patient was found unresponsive, in vfib arrest with an oxygen saturation of 60%. Despite resuscitation efforts, he expired. Consensus from the medical team was that he likely died of a massive pulmonary embolus.
Discussion:
Homeless patients make up a significant percentage of the inpatient population. This clinical vignette reveals two uncomfortable truths that exist in medicine. The first is the presence of unconscious bias. In this case, there was an assumption made that this patient had schizophrenia because he was homeless and had bizarre behavior, overlooking hypercalcemia as the cause of his acute psychosis. These biases are more likely to occur in ED and inpatient settings where quick decisions need to be made, and often result in mismanagement and further marginalization of these vulnerable patients.
Secondly, the health care system assumes that patients are capable and empowered enough to navigate its complexities, when in reality many are not, especially those who are socially disadvantaged. In addition, admission criteria, discharge instructions are a few examples where our heatlthcare system assumes patients have housing and support. In this vignette, the patient who was previously independent for 15 years on the streets was left flailing, unable to advocate for himself and became disempowered with each barrier placed before him. While internal bias exists on an individual basis, it also exists on a systemic level, increasing the health care gap of those who are socially disadvantaged.
Conclusions:
Individual and systemic bias occurs despite the best of intentions, frequently in the fast paced, time-pressured, ED and inpatient setting. These biases contribute to heath disparities and discrimination. Awareness is a start to improving these tendencies, especially with our socially disadvantaged patients.