Mobile docs: Caring for the unhoused

Dr. Roger Walmsley: bringing care to Nanaimo’s streets with a team on a missionIf you’re an emergency medicine specialist, you are used to responding quickly to incoming patients’ needs, with all the drugs, equipment and diagnostic tools you need at your fingertips. Dr. Roger Walmsley has dual certifications in emergency medicine and addictions. He works that way about half the week. For the other half, instead of reaching for scrubs, he might grab a good raincoat. He lives on Vancouver Island, on Canada’s wet coast, and—together with a team of nurses and social workers—he works on the feral streets of Nanaimo or in tent encampments.His panel of patients? “A lot of homeless individuals, some of them quite senior, some of them younger and just living out of vehicles or living in the woods,” Dr. Walmsley said in an interview.Anyone who is out there is in need of care, he said—many of them with mental health and/or addictions, along with sometimes-undiagnosed medical issues.It’s called the PCO team, as in primary care outreach—an initiative that started in 2020 with Dr. Walmsley and a couple of nurses, driving their own cars with some COVID-19 funding.Now it’s been formally evaluated and is fully supported by Island Health, the local health authority. The Nanaimo and District Hospital Foundation has purchased them a five-metre (17-foot) “Sprinter” van where they can see patients privately, draw blood, do wound care, manage diseases doctors normally treat in the safety of their office, coordinate with hospital specialists as needed, and so on.Former teachers, librarians, mill workers, construction workers. . . . “I’m just running through my list of the people that I’ve dealt with over time that have had good careers and for some reason—marital setbacks in some cases, mental health issues, traumatic brain injury or whatever, they’re now on the street, struggling to get by day to day,” Dr. Walmsley said.Sometimes people get forced into using substances by the homelessness itself, Dr. Walmsley said, “to be able to stay warm and alert in the cold weather, so they don’t lose everything.”He estimated that over a three-month period, out of Nanaimo’s population of roughly 2,000 street people, about 1,000 would be seen by the PCO nurses, and 600 or so would be seen by the physician.Having the van has made a huge difference to the PCO team’s ability to care for patients. “Before, they wouldn’t be able to access care for virtually anything. Now, we can co-ordinate their internal medicine care, their heart function—if they’re struggling with congestive failure or need a respiratory consult because of their years of smoking and inhalation products. We can at least offer to connect people with some of the services they deserve.”Dr. Walmsley is also involved with a substance use support outreach team that works on the streets. “Yes, we do see people who really do get on the road to recovery. . . . They’re living back with their partner, in a good, stable home setting, they’re providing—doing some work and feeling like they’re getting back to being a valuable citizen and participant in society.”“It’s very fulfilling,” he said. “I think what we lack in the way of four walls we make up for in terms of the connections that we make with individuals who have been very disenfranchised.“I don’t want to glamorize this in a way that or say that it’s better than other forms of care,” Dr. Walmsley is careful to add. “That’s not it. It’s providing care for those people who have otherwise not been able to access care. And in doing so, you’re providing an open door and connecting them in a way that is not stigmatizing.“It’s very different from working in a clinic or ER—and yet it’s not: “Most doctors know that when they are one-on-one with a patient, there’s a story,” Dr. Walmsley said. “There’s a need to listen and provide the care that’s needed at the moment. That goes whether you’re sitting in an emergency room, in a cubicle, or beside the road tending to someone who’s got, you know, a broken limb, or just (someone) struggling with an infection. It’s the patient that sets the agenda, wherever you meet them.” Dr. Naheed Dosani: from a refugee’s son to a trailblazing palliative care physician“I grew up the son of two refugees who came to Canada from Uganda in the 1970s, fleeing war and persecution. I always knew that the social determinants of health and community well-being were an important part of what it means to be healthy in a country like Canada.”That’s Dr. Naheed Dosani, the medical director of Kensington Hospice at Kensington Health in Toronto, and a palliative care physician at St. Michael’s Hospital. Most of the time, though, you won’t find him in those corridors. He’s driving around the city in his black Mazda, providing palliative care for those experiencing homelessness.As a family medicine resident at the University of Toronto he found himself caring for Terry, an unhoused man in his early 30s who struggled with mental illness and neck cancer. Terry had presented in a pain crisis at a local shelter where Dr. Dosani was working. “I got to work the next day, and found that Terry had died overnight. It was very traumatic, not only for his street family, but for me,” he saidTraumatic and life-changing. “I realized there was a lot of work to do in bringing about health equity for unhoused people. That’s kind of how it all started,” Dr. Dosani said.His priority became to learn everything that was known about providing healthcare for unhoused people. He then pitched models to organizations dedicated to health justice and equity. In 2014, he founded the Palliative Education and Care for the Homeless (PEACH) program, which he still leads in Toronto. PEACH is a partnership between Inner City Health Associates, Toronto Central Health at Home and Kensington Health. It has provided palliative care for a thousand people in its 10-year history, carrying caseloads of about 120 people at any given time.“There can be harsh weather—working outdoors. There’s the emotional toll of witnessing immense suffering,“ Dr. Dosani acknowledged.But, through these hardships, he believes that when you offer unhoused people palliative care that’s trauma-informed and person-centred, care that recognizes the social determinants of health, “incredible things can happen.”That can include being able to help people get basic food and medications, housing, or income support through social assistance.PEACH does what it can to support every person with a “home” death, providing them space in a shelter, rooming house or a hospice, depending on where the person is comfortable.“We hold grief circles with the shelter community, where we gather people who are working with people who are dying in the shelter system, or have died in many cases. We gather to talk about our grief in structured spaces that are supportive.”Dr. Dosani said the memories of his patients live on in his heart. “They remind me of why this work really matters and why we need to continue to advocate for a more just and compassionate society.”He is a young physician and the father of young children. “I don’t see myself ever stepping away from this kind of work. It has defined who I am as a physician and as a human,” he said. “I would argue, though, that the work is just as (medically) rigorous and academic as traditional office-based work or academic roles.”People experiencing homelessness are 28 times more likely to have hepatitis C, he pointed out. They are five times more likely to have heart disease and four times more likely to have cancer. Average life expectancies for unhoused people in Canada range from 34 to 47 years old.“Homelessness cuts a person’s lifespan by 50% and so it goes without saying that people experiencing homelessness are arguably Canada’s sickest sub-population. And given the strength of this data, clearly and unfortunately, palliative care must be a fundamental part of any homeless healthcare system that we develop,“ Dr. Dosani said.

Mobile docs: Caring for the unhoused

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