Matthew Kinsella
Browns Mills, New Jersey, United States

As the new triage nurse on  the City Department Of Homeless Services Street Outreach Team, I could observe at first, orient, get my bearings.

Well acquainted with the stark reality of life on the street, my three interdisciplinary teammates  explained the “proper etiquette” as we traveled behind the city’s glamorous neon façade; probing the grim honeycomb of desolate alleyways, tramp camps, industrial ruins, and assorted dens of ill-repute. Navigating the equally labyrinthine bureaucracy of state and church programs for the needy would  come later.

With Miesha the clinical social worker at the wheel of the Ford outreach van, Perry the team psychologist and Juan the alcohol and drug treatment counselor detailed tonight’s foray to the historic city park on the panoramic waterfront.

Major tourist destination by day, night transforms the deserted park into an ideal schoolhouse for a crash course on everything you probably never wanted to know about the ravishes of chronic drug addiction, the soiled insolence of alcoholic encephalopathy, unpredictable mental illness, the grievous outrage and posttraumatic stress disorder of the disproportionate percentage of military veterans, the desperation of the fugitive, and just perhaps, everyday miracles.

My preliminary nursing curriculum, not for the squeamish,  prepared me for the lice, scabies, maggot infested wounds, antibiotic resistant tuberculosis, hepatitis, and lurking HIV.

Setting the tone for tonight’s  course of studies, Perry plays Joan Baez:,”There but for proverbial fortune go you and I….”

Approaching the panoramic park in a soft evening drizzle, Miesha pulls the van behind a well-groomed hedge of sweeping junipers that screen a dozen padlocked trash dumpsters, concealing an illicit homeless encampment.  Juan demonstrates Street Lesson Number One, to take shallow breaths through my mouth, for what it is worth. The stench does not linger but clings, pervades. Departing the van there is a loathsome “hiss” from the ash-grey, teat-heavy Norway rat looping under a dumpster with her whelp of progeny, scattering a congressional hearing of cockroaches.

Following Perry’s lead we  approached the detritus strewn camp obliquely,  always leaving an already nervous clientele an escape route.  Selecting a particularly forlorn site, Perry takes a knee beside an iconic cardboard studio condominium, the front door: an army surplus horse blanket.

The fetid odor of wet wool is almost a welcome relief.

“Hello, Friend. Outreach.” Calls Perry.

Nothing.

Juan gives the soggy roof a gentle tap. “Hello?”

“Hello your–expletive-self,” comes a snide slur from the shadowy innards.“Get lost!”

Hip to the outreach game the street-wise know to respond before you can call 9-1-1 and they are involuntarily carted to the drear city welfare hospital, put through the wringer, and tossed back out the door with what few possessions they had gone.

“So far so good,” says Juan folding his arms in wry consideration.

Sneaking a peek within, Perry’s eyes dilate ominously. “Nurse!”

And just like that, orientation is over.

Triaging priorities and placement options: does the individual present as primarily medical, psychiatric, chemically dependent, or “merely” socially bereft? Not that the distinction ever seems that unilateral.

Here, a head-to-toe field assessment reveals an emaciated thirty-something female huddled in a fashionably matching crumpled blanket. Her breathing is wheezy, sonorous, and curiously fruity; as in a diabetic or malnutritional ketoacidosis. Her pert nose and sallow cheeks are a spider’s web of burst capillary petechiae, indicative, despite her age, of advanced alcoholism. And in the crease of an elbow, as she waves you away, seeps an open abscess. The sweetheart’s street name, the only one we will ever learn, is Sunday Sally Rose.

How could this be? In a land of more than plenty, the so-called richest nation ever, how…

“How could it not,”  counters  Juan pensively

“Amen,” adds Miesha sadly, indicating yet another tell tale symptom. Exposed below a once enticing Victoria’s Secret bustier glares a suprapubic scar, a C-Section. Sunday Sally is someone’s mother?

According to the Journal of the American Medical Association, over the course of one year two to three million Americans will  become homeless;  ten to twenty percent of these will become chronically transient. Sixty percent of the latter will be chemically dependent and, doing the staggering math, fifty-seven percent mentally ill.  Seventy-five thousand will wander the streets of this one city; one-hundred-grand subsist at institutional public shelters; and another anxiety-ridden million are no more than the next paycheck away from destitution.  Particularly harrowing, according to the Covent House Youth Project, five-thousand homeless children will die from neglect, abuse, suicide, and untreated illness.

The statistics do not seem to impress Ms. Sunday Sally Rose. “I’m fine! Here…” To get us off her back by way of demonstrating an adequate degree of self-sufficiency, she digs into a Styrofoam Salvation Army meal-and then suddenly panics, vacating her condo in a phobic hysteria.

Reconvening at the overturned meal is a senate subcommittee of roaches.

“Thank you for the help,” salutes Juan flippantly.

“Heaven help us.” Miesha makes a sign of the cross and joins Perry in taking advantage of the moment to coax, coach, and half-carry the diminutive bundle of exhaustion, neglect, and derision to the van.

“So where to?” asksPerry, securing Ms. Sally’s seatbelt in the van. She bats her eyes at him coyly, her jaundiced sclera the color of dead daffodils.

Where do you even begin with a possibly asthmatic, diabetic, anorexic, alcoholic drug addict on the verge of mental instability? Chronic medical concerns aside, as Juan explains, our Sunday Sally is probably too emotionally fragile to profit from a drug recovery program yet too addicted to profit from a mental health program. And the dangerous public shelters you would not wish on anyone but a lost dog.

“Not for nothing,” Miesha intervenes with an oddly mischievous grin, “I got an idea.”

“Not again!” equivocates Ms. Sally, scratching furiously at a once luxurious mane of hair. Circling her wrist dangles a souvenir bracelet of three name bands from previous vacations at the city welfare hospital.

As Miesha turns the van left out of the park, Juan and Perry look right, confused.

“Uptown, that’s right,” says Miesha preemptively. “The Emergency Department at the prestigious University Medical Center.”

“You’re the one that’s nuts!” exclaims Perry.. “Look at her. Ten-to-one no medical insurance, no money, no I.D. And no acute medical distress. We won’t get past the intake desk.”

“Nurse!” As Miesha lays out her scheme, sure enough we are barely out of the outreach van at the uptown emergency department before a burly security guard is already waiting at the intake desk.

“Oh, no no no, you don’t! Take whatever that is to the welfare hospital as you’re supposed to, and where it belongs. “

“Been there done that,” shrugs Juan as he steps forward with Perry.

“What part of NO don’t you understand?” Radio in hand, the security guard’s trigger finger hovers an inch above a red alert button. On her black leather belt dangles a holstered taser and can of mace. Over her shoulder in the waiting room a dozen eyes watch the unfolding floorshow blankly.

“Madre de Dios!” Miesha joins Perry and Juan, forming a unified front. Which, by the process of elimination, left me,,shielded behind their backs, to tend to Sunday; and she is nauseous from car sickness. Closing ranks Miesha leans into the officer’s ear in a conspiratorial whisper. “We didn’t want to mention this, confidentiality and all, but ‘it’ is a she, and she is the daughter of your hospital C.E.O.”

“Bull…!” stammers the guard, but not without a suspect flicker in her eye.

Miesha turns back toward the exit, obliquely. “And we hear that she is a real daddy’s girl; but it’s up to you.” Slowly walking away, Miesha jangles the van keys.

Street lesson number two: are clinical social workers allowed to lie, even little white lies?

And lesson number three: Miesha can not be covertly gesturing to me, can she? Yet Isee her scheme now. While they divert Security there is a beeline to the sanctuary of the nurse’s empty triage station, where  as soon as the nurse applies as much as a blood pressure cuff to Sally she is home free. By law  she must then receive full ongoing care. Blatantly misappropriating resources and transgressing policy and procedure will more than likely generate an incident report, and  once the grievance hits your supervisor’s desk in the morning then I too may be home free; as in a termination notice from my new job, if not also jeopardizing my nursing license .

Radio in one hand, the other at her holster, the security guard steps over to Miesha, spittle flying, calling her bluff.  “Then name the hospital CEO! Go ahead.”

Now or never, tending to Sunday I can almost hear the wily smile in Miesha’s reply. “You know the CEO as well as I do. The Celestial Executive Officer. That’s her daddy. And, again, one of his most precious children from what I understand.”

Tumbling into the van, and heading back to the park, Perry and Juan offer outreach lessons number four and five. Four: Sunday Sally may be a medical and/or psychiatric, social, and addiction concern. Yet primarily what Ms. Rose is, is our everyday miracle, like universal healthcare, just waiting to happen.

And Five: the coffee shop at the corner of 23^rd and 7^th makes the best cappuccino grande.