Category: Observations

Categories
Fiction Lessons Observations

Stoicism.

“I HEAR THEM! THEY ARE CALLING ME A CHEAP PROSTITUTE!”

Her shouting is like a gas: It completely fills the space, regardless of the size of the container. The sound originates deep in her abdomen and bellows from her mouth before reverberating throughout the room.

“THESE DISGUSTING MEN,” she shouts, “KEEP CALLING ME A WHORE! I AM NOT A WHORE!”

Her wrinkled hands flecked with liver spots loosely hold a fashion magazine open. Long strands of her gray hair are falling into her dark eyes.

“I HATE ALL OF THEM! THEY ARE SO DISGUSTING!”

Spittle flies from her chapped lips as she roars. Her eyes are focused on the empty chair directly across from her.

“IF THEY KEEP CALLING ME A DIRTY WHORE, I WILL SLIT THEIR THROATS! ALL OF THEM!”

A receptionist, a doctor, a nurse, and a dietician all stand around her in the waiting room. The shouting woman is waiting for her appointment. The staff are waiting either for her to calm down or for the last cue to escort her out.

Silence fills the room like a gas. The woman’s lips are stretched into an uncomfortable grimace.

Seated directly to her right is an older man. He still has not looked around the sheet of newsprint he is holding. He has not shifted position. The newspaper does not rustle.

Seated to her left is another man who is holding a small cell phone in his right hand. His right thumb periodically pushes a button on the phone and his eyes remain fixed on the small screen.

Two men and one woman are seated across the room. The woman continues to dip her crochet hook into the yarn; the hook has not stopped since the shouting began. One man has his arms crossed; his chin is tucked in and his eyes look closed. The other man rests his elbows on his knees, his fingertips lightly touching, and his eyes stare at the floor. If he has flinched, no one has noticed.

“STOP CALLING ME THAT!”

This story isn’t about her. It’s about the other people in the waiting room.

What happened in their lives that gave them the stoicism to completely ignore her?

They didn’t get up. They didn’t change seats. They didn’t stare with curiosity or fear. They didn’t look at each other with knowing eyes.

None of them had met her before, but they were already familiar with her behavior.

What happened to all of them?

Did their parents only scream at them? Was a shouting parent more comforting than silence, as that meant that at least a parent was present? Did they learn to tune out the shouting when they were incarcerated? Were they beaten as adolescents, such that shouting like this was a benign alternative? Did strangers only shout at them, making this situation nothing out of the ordinary?

How did they learn to cope like this? Who or what trained them to react like this, to react with nothing at all?

Categories
Homelessness Lessons Medicine Observations

Saying Good-Bye.

I originally wrote the post below over five years ago. It’s about a teenager I worked with for about six months at a residential treatment center. I still think about him from time to time; I hope that he was able to exit the mental health system.

A few months later, I learned that, less than 24 hours after we said good-bye, he injured himself while destroying property. He apparently threw chairs, punched walls, and tried to knock over bookcases and other pieces of furniture. There was no obvious trigger. It took four adults to subdue him. Staff commented that he had not behaved this way in over two years.

“That’s how he dealt with termination,” a staff psychiatrist murmured.

I’m still not sure if I agree with him.

I’m still not completely sure of the optimal way to proceed with termination.

Termination refers to the end of the therapeutic relationship between patient and physician (or, more specifically, psychiatrist). There are essentially three ways termination can occur:

  • Patient exits the relationship (patient stops attending appointments; physician fires patient; s/he dies)
  • Physician exits the relationship (s/he dies; patient fires the physician; physician disappears)
  • Patient and physician mutually agree on a final appointment date and time and complete the session

Ideally—for both parties—the last option occurs. This allows “closure”. And, no, I’m not entirely sure what comprises “closure”, but the lack of “closure” is why many break-ups suck. Think about it: Break-ups are uncommonly mutually agreed upon events; usually one party decides to unilaterally bail, resulting in negative emotions all around.

In therapy, we do not want to recreate break-ups; instead, we want to model and engage in the graceful end of effective and meaningful relationships. (Psychobabble.)

Saying good-bye is difficult. The white coat-wearing medical doctor within the psychiatrist bristles at the idea of termination; there is something about our medical training that promotes the idea (“virtue”?) of emotional distance and independence from our patients. So many things about our profession (both intentionally and unintentionally) facilitate this: Doctors wear white coats. Doctors wear gloves. Doctors ask a lot of questions, but rarely answer any. Doctors aim for objectivity and evidence.

So when we psychiatrists terminate with patients, the experience is weird and we are often surprised with how difficult it can be.

It’s never too early to initiate termination, so I had informed the adolescent male three months prior to our last appointment together that our time was drawing to a close. At the time, Andrew said nothing.

It’s not that he didn’t have anything to say about it; I had learned by this time that he heard practically everything I said, even though his behavior often purposely suggested that he was ignoring me.

A month prior to last our last appointment together, I reminded him again of my departure.

“Have you seen that Geico commercial? You know, the one with the little kid imitating a monster?” he replied.

As the days passed, he spontaneously mentioned the limited time we had together, though he tossed his remark within a smokescreen:

“I can’t believe that happened; it kinda makes me sad. You and I have three sessions left; we have to make the most of them. So I think I am going to try asking her again, maybe when she’s not so depressed, but it’s hard to tell….”

And that’s the way it had been the entire time we spent together; he would share bits of himself—often only a sentence here, another one there—at random intervals. Sometimes he would acquiesce if I asked a few questions to clarify his remark; most times, he simply changed the subject. One day, I called him on it.

“You’re really good at changing the subject when I ask you questions.”

“Yeah, I know,” he nonchalantly conceded, “I don’t like it when people care about me. It makes me feel weird.”

And when I tried to ask him more about that, he promptly commented on the weather. I smiled—sadly—at him.

The last time I saw him, he greeted me warmly.

We learn in the course of our training that therapeutic termination includes reviewing the time spent together and commenting on progress and goals attained. It’s like a summary statement, an opportunity to reflect upon how the patient has changed and how the patient can continue to effectively pursue his goals.

I already anticipated that, though he would hear my monologue of the above, he would not respond. My hypothesis bore true.

I commented on our very first meeting and what he stated were his goals at that time.

“Did I tell you the joke about the buffalo?”

I continued to commend him for the significant progress he had made in several spheres.

“What did the mother buffalo say to her kid as he left for school?”

I then reiterated his strengths—he had so many: he was so good with people; his integrity was admirable; he was intelligent and thoughtful; he was fiercely independent and more than capable of taking care of himself.

“Bi-son!”

I expressed my hope to him that he would continue to pursue his dreams—I was (and still am) confident that he could reach all of them.

“How about the one about the cowboys?”

I looked at him, willing him to participate in the conversation—but I knew saying good-bye was not his strong suit. His parents had abandoned him when he was young; there was no such thing as a “healthy” good-bye in his experience.

“Because they are too heavy to carry! HA!”

“Take care of yourself,” I said, patting his shoulder. “Good-bye, Andrew.”

He had already started to walk away when he answered, “All right.”

I watched his lanky figure amble down the hallway. I then quickly turned to go.

Categories
Education Medicine Nonfiction Observations

CPR and Informed Consent.

Radiolab recently aired a show called “The Bitter End” that discusses the end-of-life care preferences of physicians and non-physicians. Physicians are much more likely to decline “heroic” measures, such as CPR, mechanical ventilation, feeding tubes, etc. This comes as a surprise to the hosts and, presumably, to other non-physicians. It’s a good show. I recommend it. (Full disclosure: I like Radiolab.)

In the show, Ken Murray argues that physicians decline these “heroic” measures for intellectual reasons. He argues that we know the data, which includes a study that reported that, of people who receive CPR, only 8% are successfully resuscitated. (Of those 8%, only a portion of them return to their full previous function.)

I don’t think physicians decline CPR and other “heroic” measures because of evidence-based, numerical data alone.

The experience of performing CPR and attending to patients who are critically ill contribute to physician preferences against CPR. It’s emotionally taxing. All physicians have seen the trauma we cause with these “heroic” measures. Yes, performing CPR can lead to cracked ribs and punctured lungs. Mechanical ventilation can lead to severe cases of hospital-acquired pneumonia. Intravenous hydration can cause massive tissue swelling. The consequences of heroic measures are often devastating.

Physicians are taught “first, do no harm.” Sometimes, these heroic interventions seem like they cause more harm than good.

Perhaps physicians decline CPR and other “heroic” measures because of anecdotal experiences and emotions. This isn’t randomized, placebo-controlled data. However, anecdotal experiences and emotions are still data.

Furthermore, there is no true “informed consent” with CPR. When patients are able to consent to CPR, they are not truly informed. They cannot fully appreciate and understand what CPR entails because they have never experienced it.

By the time patients are truly informed about CPR—when someone is pushing on their chests, when a second person is manually inflating their lungs, when a third is injecting medications into their blood, when a fourth is trying to stick a breathing tube down their throats—they are unconscious. They cannot offer or withhold consent.

(This is true with many things in medicine: No one can give true informed consent for general anesthesia, surgery, or even medications. We often only know all the information after the fact. Patients often give consent based on hope and faith.)

Physicians see and treat patients who have undergone CPR. Those patients are usually paralyzed, swollen with fluid, and unconscious. Upon witnessing that, physicians might wonder what the differences are between “living” and “existing”.

This could explain why their end-of-life care preferences differ from that of the general public.

Categories
Education Nonfiction NYC Observations PPOH

Daily Schedule: Assertive Community Treatment.

A sample agenda as the consulting psychiatrist with an assertive community treatment (ACT) team:

7:55am. No one is at the office yet. Insert a key into the gate in front of the building. The gate makes grating and squeaking sounds as it rolls up. After entering the building, quickly disable the alarm, lock the door on the way in, and roll the gate back down. From the medication room, pack into a brown paper bag a pair of gloves, two alcohol pads, one band-aid, a pinch of 2×2 gauzes, a portable sharps disposal container, and a pocket-sized bottle of hand sanitizer. Unlock a different cabinet and fish out a small box that contains liquid haloperidol decanoate, a long-acting antipsychotic medication. Drop that into the brown paper bag.

Leave the office, secure the building, and make sure that the gate is rolled completely down before walking away.

8:40am. Arrive at a patient’s[1. All patients described here are composites of people I have seen across time.] apartment uptown. She lives with her mother, grandmother, and her mother’s boyfriend. As usual, she’s still sleeping, even though she knew that this visit would occur around 8:45am. She’s wearing a strappy tank top and baggy pajama pants. She rubs the sleep form her eyes. She walks back into her bedroom. An electronic rose is in the corner next to her mirror. Different colored lipsticks are on the table. There is a desk lamp on the nightstand, as well as several magazines.

She shrugs her shoulders after realizing that her offer of a seat on the unmade bed was politely declined. She’s doing pretty well: She’s re-enrolled in GED classes and is studying to take the test, though she’s finding the math portions difficult. She’s still going to the local bar on weekends, but denies getting drunk. When she also denies smoking marijuana, her response seems honest, though her next visit to the office will include a urine drug screen test. The antipsychotic medication isn’t causing side effects. She asks for advice on how to avoid bad boyfriends.

9:30am. Arrive at the second patient’s apartment after a subway ride further uptown. He lives with his elderly parents. He’s not doing well. He yells at his mother and his father often locks himself in the bedroom so they don’t have to interact.

He begins to share that he is dating a woman, then suddenly comments that he hasn’t drank any alcohol in months. His mother interjects and says that he has come home very late at night smelling of alcohol. The stories from the past week spill from her mouth; she’s watched him cross and re-cross the same street for two consecutive hours. Sometimes he yells about the gods who have failed him. Small items—vases, salt and pepper shakers, silverware—have started to go missing from the apartment.

He says he’s taking his medications, but his mother says that she finds pills in the trash cans. He mumbles under his breath.

No, she hasn’t had to nor wanted to call the police. No, he doesn’t want to go to the hospital. He’s eating the ham and cheese sandwich that she’s made for him. She asks what will happen next.

“If you feel unsafe, call 911 and call the ACT team. Don’t wait. Just call. We’re all worried about him.”

He rolls his eyes and asks the wall why anyone would think he would hurt anyone. He doesn’t seem to remember that the last time he developed symptoms and drank alcohol, he punched his daughter.

10:40am. Arrive at the third patient’s apartment after a bus ride across town. He’s an elderly man who believes that his neighbors have stolen his internal organs and that cannibals will eat him if he leaves the building. These beliefs as well as gait problems keep him in his apartment. This is the person who will receive the haloperidol injection.

The usual conversation about his medication ensues. He’s willing to accept the medication, but wants to discuss again why it is at its current dose. The reasons haven’t changed from last month. He nods in what seems to be understanding, though then asks, “The medication will not make my skin turn blue, right?”

This is a significant improvement from a year ago.

Three large cockroaches skitter across the countertop. Two empty cartons of orange juice sit on the kitchen table. He looks into the living room, which holds his bed. He doesn’t go into the bedroom anymore. He still cries when he thinks about his dead wife.

He rolls up his sleeve and looks at his arm when he receives the injection.

“It never hurts when you do it.” He’s probably just being nice.

11:45am. Arrive back at the office. A patient sits on the curb, smoking a cigarette, while chatting up a cab driver. Everyone says hello to each other.

11:50am. Two of the social workers are in the office. They and the secretary all share events from the morning. One of the ACT patients may leave the hospital tomorrow. One of the social workers will escort him directly from the hospital back to the apartment if the hospital discharges the patient.

“I’ll visit your guy tomorrow morning,” the other social worker says, referring to the second patient who lives with his elderly parents. “We’ll check in with him every day this week.”

12:00pm. Work on documentation from the morning visits. Mindlessly eat lunch.

12:53pm. Fourth patient arrives for his 1pm appointment. He greets everyone with a warm smile.

He recently started volunteering at the library and teaches young children how to read. He rides his bicycle around Central Park to help keep his blood sugars under better control. His daughter is coming to visit for the holiday. He plans to cook salmon for dinner tonight. He’d rather have fried chicken.

“I’m scared to lower my medication, Doc,” he says. “I don’t want to end up at the hospital again. But if you think all this weight gain might be from the medicine, I guess we could try it—you said real slow, right?”

After some more discussion, he concludes, “No, let’s not change the medicine now. Lemme get through the holidays and then we’ll try. Real slow. Real slow.”

His wishes are honored without argument.

2:00pm. The fifth patient hasn’t arrived.

2:10pm. The fifth patient still hasn’t arrived. She’s more organized than people might initially believe, but she’s rarely punctual.

2:17pm. “Heya doc, how you doing, how you doing,” the fifth patient says, flopping down on the seat. She’s chewing on a popsicle stick. She’s tied the two ends of a necktie together and is wearing that around her neck like a necklace. Four other neckties are tied around her neck the same way. Ear phones cover her ears, but they’re not plugged into anything. Her striped socks are pulled over her baggy sweatpants.

“Heya doc, how you doing, how you doing, the vapor’s hot today, so hot. The icicles bring down the vapor, the vapor pulls the magnet and the poles spin, they spin, that’s what makes the Earth spin, the vapor around the Earth spins, too, spins like a record, so cool, so cool….”

She just finished her first week as the filing clerk for the drop-in center. The staff there said that she did good work and that she seems to like it, but she occasionally breaks out into song.

“Do you like your new job?”

“Yes, yes, but I want them to like my new job, too. I like the money, too, I can buy myself some new shoes, new blue shoes, new blue frue true krue shoes, so krue, so cruel, cruel world.”

On the way out, she flings the popsicle stick into the trashcan and belts out, “NEW YOOOOORK… CONCRETE JUNGLES WHERE DREAMS ARE MADE OF….”

3:05pm. Sixth patient arrives. He sits down and looks out the office window into the lobby. Everyone said hi to him as he walked in. He didn’t respond.

He doesn’t say anything in the room. He doesn’t make any eye contact. He examines his nails. He reties his shoelaces. He rolls up his pant legs. He strokes his beard. He fishes a half-smoked cigarette out of his pocket, then puts it back in.

“What’s going on? Is something wrong?”

He sighs and shakes his head. He gets up and doesn’t look up in acknowledgment when he hears entreaties to stay. As he walks out of the office, he finally says, “I’ll be back.”

3:20pm. Ask one of the social workers to follow the Tacit Man out of the building with hopes that they will have a conversation.

3:22pm. Watch from the lobby while the social worker and the Tacit Man talk. They’re actually speaking to each other.

3:25pm. The social worker walks back into the building and the Tacit Man walks across the street.

“Tacit Man is fine, just having a bad day,” the social worker says. “He’ll come back tomorrow to see you, same time.”

“Thank you!”

3:27pm. Call patients to remind them of meetings scheduled for tomorrow. Most of them answer their phones.

3:45pm. Resume documentation with occasional interruptions from other patients wandering into the office to say hello.

4:35pm. Coordinate plans with the social workers for tomorrow. Discuss medication changes, medication deliveries, and which patients need closer monitoring.

4:45pm. Leave the office. That same client who was sitting on the curb and smoking is still sitting on the curb and smoking. He waves hello. I wave back.

Categories
Education Homelessness Medicine Nonfiction NYC Observations PPOH

Daily Schedule: Homeless Outreach Team.

A sample agenda as the consulting psychiatrist with a homeless outreach team:

8:17am. Arrive at the office, which is in a tall building that is a short walk from the New York Stock Exchange. Speak with the case managers and social workers about who should be seen that day.

8:55am. Walk with a case manager to the ferry terminal meet Paul[1. All patients described here are composites of people I have seen across time.], who is a young man the outreach team has seen over the past two weeks, particularly in the early morning. Paul has said that he lives with his father in Washington Heights. When asked why people see him at the ferry terminal at night, he only repeats that he sleeps in his father’s apartment at night and walks the 10 miles to and from the ferry terminal every day. He doesn’t say much to people, but he’s often mumbling to himself. The security guards have shooed him out. He returns everyday.

He’s sitting in a chair with a ripped jacket draped over his head. Dirty sweatpants that are three sizes too big hang off of his slender frame. When he hears “good morning, outreach team” for the third time, he slowly pulls the jacket off of his head. His eyes are closed. When he hears “are you okay?” for the second time, he opens only one eye. With some prodding, he says his name, but says little else.

“I gotta go to work,” he says as he gets up. The sweatpants begin to slide down his hips. He’s not wearing any underwear. He starts to walk away and the legs of the sweatpants begin to bunch around his ankles.

“If you want, we can get you a pair of pants that will fit you better—”

He starts to walk faster and does not listen to entreaties to stop. With his left hand he grasps the waistband of his pants and walks down the escalators. He blends into the crowd of people exiting the terminal and is soon on the road outside, walking north.

“That’s Paul,” the case manager says.

“We’ll try again tomorrow.” Provide teaching on different strategies to build rapport—maybe present him with a pair of pants? a package of underwear?

9:20am. Say good-bye to the case manager and hop on a subway and head uptown, but don’t exit the station. On a bench near the rear of the station is Eleanor. She’s been homeless for over twenty years. She’s wearing two jackets and her fingernails are painted pink. No one has ever seen her nails unpainted. They always look manicured.

She’s darning socks with her wrinkled hands. Nearby is her large rolling suitcase, which is open today; inside are more jackets, several pairs of shoes, and two large bags of potato chips.

“Hello,” she says quietly. She smiles. She reports that she is fine, but her back hurts this morning. She wasn’t able to lie down last night to sleep. The security guards frequently asked her to move.

“You could move into a small apartment where security guards wouldn’t bother you. It would be your own space.”

“Oh, but I can’t,” Eleanor says. “They will exterminate me if I do that.”

She’s said this consistently over the past seven months.

“The alien transmissions—they use the satellites—tell me that I’m not allowed to move inside. They’ll exterminate me if I do. They’ll use electrocution. I don’t want to be exterminated. I can’t.”

With much coaxing, she’s actually been able to visit a housing project to see a studio apartment, but she refused to actually step into the room.

“I’ll get exterminated.”

She also declines to take any medication.

“The only medicines that work are potato chips and chocolate. Dark chocolate works better than milk chocolate. I feel better when I eat chips and chocolate.”

It’s hard to argue with that. She declines housing again today, but she’s open to another visit later on in the week.

10:00am. Get back on the subway and get off at the stop two stations away. Climb the stairs out of the station. Barry is sitting cross-legged in front of the bodega. He’s rocking back and forth while smoking a cigarette. Barry says he’s been homeless for the past eight years and the bodega owner says that Barry has been sitting out there for the past five years.

“I’m sorry,” Barry greets. A stranger leans over and leaves a deli sandwich and coffee for him. Barry mumbles, “Thanks.”

The dirt on his arms and hands indicate that he hasn’t showered in several weeks, maybe a month. Dirt is packed underneath his fingernails and bits of food are stuck in his beard. His fingertips are yellow and knobby with callouses.

“I gotta get back to work, I gotta get back to work,” he says, pointing at the building across the street. “I think my boss would give me a job again, I did good work while I was there, I did good, I did good.”

Barry also declines housing again today. “I gotta get a job first before I get an apartment. A man’s gotta work first, he’s gotta work, I gotta get back to work.”

The office receives his monthly cheques for disability (schizophrenia), but he won’t withdraw any money. His bank account has tens of thousands of dollars in it. He could afford to rent a small room, but he won’t do it. He can’t say why.

“It’s starting to get cold. If you don’t want to move inside, can I at least bring you a jacket or two?”

Barry stubs out the finished cigarette. He stops rocking.

“Yeah, sure,” he finally says.

11:00am. Team meeting. Discuss progress on different clients the team is following. Two people moved into transitional housing in the past week! One moved into permanent housing. People are excited about the individual who moved into permanent housing because he was homeless for over ten years. He often shouted at and hit himself for sins he said he committed. Despite that, everyone liked him, including the police, because he also had a sharp sense of humor. He also fed the pigeons every day.

He refused to move inside for over a year. After multiple visits to the housing project, he finally said he would give it a try. It’s been three days and he hasn’t left. Sounds like he was adjusting fairly well to his new digs, but he still sleeps on the floor.

12:00pm. Lunch. Chart the encounters in the morning.

12:45pm. A case manager brings a man to the office who is willing to sit for a psychiatric evaluation. A plastic bag hangs from the man’s hand. Inside is a brown paper bag that holds two 24-ounce cans of beer. One of them is open. He looks down at the bag.

“I won’t drink this now. Please don’t throw them away.”

He’s been homeless for four years. He was sleeping on the floor of the pizza parlor where he worked as a sweeper, but the owner was closing the business because of financial problems. He now sleeps on trains, in subway stations, sometimes in parks. He tries to avoid the shelters because people have stolen things from him.

“I know I have an alcohol problem,” he says, his eyes sad. “It wasn’t always this bad. I don’t know how to stop. Sometimes I think I will never stop, even though I hate waking up in the hospital. Life is too hard. Beer helps me feel better. ”

1:45pm. Charting that encounter. Diagnosis determines what housing he is eligible for.[2. “Diagnosis determines what housing he is eligible for.” This is an example of psychiatrist as an agent of social control.] It’s not clear if he has a “severe and persistent mental illness”. Suggest that he return in a week; the meeting can happen outside if that’s easier. No recommendations for medications right now, but harm reduction in his alcohol use would probably be helpful. He demonstrated insight, but that may not result in behavior change.

1:55pm. Case manager asks for help with a person who lives in a park. Hop into the team vehicle and drive north.

2:20pm. Arrive at the park. The client was there earlier in the day and said that he would be there, but a walk through the park shows that the client isn’t.

Three people by the picnic tables wave hello. The outreach team sees them regularly, though they are not eligible for this program. They have been drinking, but they are not grossly inebriated. They laugh as they tease us for following them around; everyone is now enveloped in the strong fragrance of fruity, sugary alcohol.

They each hold a bottle of beer that sits inside a wrinkled brown paper bag. They offer some. They aren’t offended when their offer is declined.

2:30pm. Walk around the park one more time to find the original client. He’s still not there. Children play with a ball on the lawn, multiple games of chess are in play, students read thin books on park benches, couples hold hands as they walk along the park paths, elderly women sit and watch people walk by. The three people who are drinking alcohol laugh loudly.

2:55pm. Arrive back at the office. A client is sitting in a chair by the door. He says nothing, but he looks upset.

A case manager requests consultation.

“This guy never agrees to come in,” she whispers. “Maybe you could talk with him? He’s been homeless for a long time, but finally agreed to move into an apartment about eight months ago. He was doing fine, even saw the psychiatrist there once or twice… but apparently he’s been sleeping outside for the past two days and won’t say why.”

There are introductions. The man doesn’t want to get up from his seat. He frequently looks at the door during the stilted conversation.

“How are you, Charlie?”

“Fine.”

He learns what the case manger shared. He says nothing.

“How long have you lived there?”

“A few months.”

“What’s it like?

“Noisy.”

“Anything you like about it?”

“It’s warm.”

He suddenly starts talking about the freedom of living outdoors, except the cops harass him sometimes. He also doesn’t like the kids who try to set him on fire. The zombies send them to do that. He’s tired of the zombies.

“Who are the zombies?”

“I don’t know! Stop asking me questions!”

He abruptly gets up. Everyone pauses.

Charlie wipes his mouth on his sleeve. He drops back down into his seat.

“The zombies want me to be homeless. Every day, same thing: ‘You’re a homeless motherf-cker’. Damn!”

He talks more about the zombies and his apartment.

“You wanna try going back this afternoon? We can take you there. It’s starting to get cold out. You mentioned that your apartment is warm.”

Charlie chews on his lip and snarls.

“Let’s get into the car so I can drive you back,” the case manager gently says. He says nothing, but he gets up and walks out of the office. Everyone looks at him.

“You gonna drive me back there now or what?” Charlie mumbles.

3:45pm. Go visit a local church to try again to speak to a young man. No one is certain of his name. He believes the church is his home: The pews are his beds, the altar is his kitchen. He has washed his clothes in the font of holy water. He occasionally yells “in tongues” at parishioners. When security guards have consequently escorted him out of the church, he has tried to “cast the devils out” of them. He notably avoids the church during formal services.

Inside the church, tourists and visitors speak in hushed voices as they walk through the aisles. The security guards nod hello.

The young man is seated quietly in a pew in the chapel. His eyes are closed. He doesn’t respond to whispered entreaties to go outside and talk. He keeps his eyes closed, his hands clasped, and he breathes quietly. Another security guard watches him.

4:05pm. Back at the office. Charting.

5:05pm. Depart the office and get swept into the current of people walking towards the subway stations. Automatically look for people who are homeless along the way. It’s too crowded right now; the homeless can’t find any places in there that offer peace.

Step onto a train and notice a sleeping man holding a tattered backpack to his chest. His clothes are soiled, including his three oversized coats and flimsy cap. The soles of his shoes are ripping off, showing the dingy yellow socks inside.

A lot of people get up so they don’t have to stand or sit near him. Most people don’t look at him.

I do.