I was visiting my great-aunt Helen, who has lived to 96 by herself. She has always been, and remains, an elegant force of nature, ever concerned with courtesy and making sure her makeup looks appropriate. Lately, time and the consequent decline of the human body has taken its toll. I went to see her in the rehab facility where she went after a recent illness.
As I walked down the hall, the noise and the chaos were striking. Because it is also a nursing home, older individuals with dementia walked the hall. Some were looking for a nurse, some simply ambled, smiling or frowning, their destinations charted in the blurry maps of their minds. Another one frantically looking for coffee, holding an empty mug.
Motorized wheelchairs moved about, the motors quietly humming. Others, without such wondrous devices, pulled themselves along in old-school wheelchairs, moving with the strength of their arms or with their feet, extended and retracted, slowly exercising while powering their chairs forward and back.
Others, apparently also there for rehab like sweet Aunt Helen, chatted with friends as they recovered from surgeries or other infirmities, not quite ready to navigate their homes.
What struck me, though, was the number of relatively young men and women, some clearly intellectually and developmentally challenged. No doubt some were victims of birth injury or head trauma. Those who had been afflicted by severe illness early in life, but lacked resources for care at home, had landed in "a facility" as we so vaguely and tenderly put it in healthcare.
It also occurred to me, as I wound my way down the corridor, that this is the future. Well, in a way. Because we will see more, and more people in need of "facilities," in need of "institutions."
Already our system is overwhelmed with patients who have severe mental illness. They live their lives, as one physician put it, "from brief psychiatric hospital stays, to the street, to jail, to the ER," in no particular order. We try to "place them," that is, find a facility for them. They aren't really treated in the ER, they are stored and watched, fed turkey sandwiches, and then sent elsewhere. Sometimes after days to weeks. The few with more permanent placement seem to struggle to stay, the chaos of their minds leading them off into the wild once more.
They come to us from the street where they are beaten, or overdose, or become ill with pneumonia or exposure. Or from the homes they return to where family, trying to be compassionate, can't help them. Of course, all too few have homes at all, or families.
Our system is also crushed by drug abuse and addiction. And the problem isn't merely solved with naloxone (Narcan), certainly not with drug legalization, which I predict would be an endlessly unraveling disaster on many levels.
The deeper issue is that drugs are associated with problems besides the cessation of breathing.
Our IV drug users, those who shoot up methamphetamine, fentanyl, or heroin (which has been run out of town by fentanyl, as if an invasive species), have recurrent infections where they inject. They become septic. They lose limbs. Their heart valves cluttered with bacteria, which slowly dissolve them. Their livers infected with hepatitis. They have terrible IV access and require special skills, ultrasound placed lines, or even permanent ports to obtain access to treat them. And treated they are, over and over, for the consequences of the drugs that they can't stop, or that they can't find or afford the help to stop using.
Others have psychosis, anxiety, and depression from their drug use. We saw a psychotic patient recently who believed that marijuana and methamphetamine helped his hallucinations. In fact, marijuana is associated with of schizophrenia. Schizophrenia is difficult to manage in the best of circumstances. Its victims tend to deteriorate, not improve.
So, many of these people will end up, at some point, in need of a "facility." Perhaps with age they will be easier to help. Maybe when they reach (perhaps) the ripe old age of 40 or 50 after decades of untreated mental illness, homelessness, or addiction, they will fit into a "facility" and will be manageable. Time will tell.
But their broken minds, their broken bodies? They will not move into apartments, much less houses, where they can function alone. Many of them have no children, or have children who cannot help them, or won't due to the pain of the years trying to help them already. The years and the struggles, the abuse and the illnesses, the loneliness and yes, the wretched poverty so shocking in a time of such wealth, will render them more helpless than sweet Aunt Helen.
Where will they go? It's hard to imagine. Already, hospitals are like clogged pipelines. Emergency departments are full because inpatient beds are full because nobody can be discharged to rehab or nursing homes because they are also full. And closing. And understaffed. Or scandalously mismanaged.
Humans are already stacked up "like cordwood" as Southerners like to say. As more people age into infirmity, as more people have untreated mental illness, as more people are fed the lie that drugs can be managed safely, that we can simply let people "do their thing" and it will all work out, as the wealth gap in society grows and the poorest and most fragile drop further to the bottom, the "stack" will become ever worse.
Right now, we need a national initiative to make places for the mentally ill, the addicted, the aging; especially those who have nothing. Right now, we need college degrees focused on the care of the aging just as we have them to care for infants and children. Right now, we need armies of primary care providers and more help for struggling ERs where the tsunami crashes every single day. Right now, we are decades too late.
But I suppose, it's better to start now than never.
Or else the pipeline backup will run outside the door of the emergency department and into every street and neighborhood in the land, beyond merely the largest cities.
Maybe when we're all stepping over one of these poor people daily, maybe when it's finally made real, something will happen.
Until then, the cordwood will either decay or burn up in endless small and large tragedies.
Edwin Leap, MD, is an emergency physician who blogs at , and is the author of and . You can read more of his writing on his Substack column, Life and Limb, where a version of originally appeared.