Please consider checking. Someone with diabetes who's experiencing a low blood sugar may act as if they're very tired or even drunk. Just giving them some fruit juice or a can of soda could save their life.
2
I am a nurse practitioner practicing in NYC facilities for nearly 15 years. I sympathize with this doctor's question. I would point out that this scenario repeats itself maybe 2-5 times on a walk crosstown from Bellevue to Eighth avenue. What we are seeing is people "nodding off." On an OR table they would be asleep. I often will pause to make sure the person(s) is breathing effectively. But I don't know how I could stop and try to arouse each person I see like this, each time, every day. The doctor describes having "an antidote" in her purse. The public should know that the half life of narcan is shorter than that of most opioids (means the narcan will work for some time, then the opioids will continue to bind to the mu receptors causing respiratory depression again.) If the person is not breathing one must call 911 either way. This goes beyond helping out on a long-haul flight meaning, here in NYC I see this scenario daily. I check to make sure the person is alive by observing or firmly and politely asking - then I have to move on. I call 911 when I have to. I've called 911 many times then waited for paramedics to arrive - after that my responsibility ends.
4
We were lucky because we have trustworthy medical doctors since 1960s. Most of them are affiliated with Hopkins, Georgetown, and George Washington hospitals. Our whole family always taken care by the "best" doctors in our area. I believe doctors in emergency situations are more important than routine visits. Two years ago I had an emergency situation and my family was able to call 911 and immediately sent me to hospital. The 911 team members were super great and the doctors in the emergency were also outstanding and that is why I am still able to make comments today. I still visit my young and dependable emergency room doctor frequently. I trust him because he saved my life. We must build a trust relations with our doctors. My doctors were trained by most reputable medical schools and interned in well-known hospitals in the nation. I am almost 90 and I am still happy and feel with confidence. But I am also ready anytime. I still remember when I was a student I rented a room nearby from my school and the landlady's son was a medical doctor downstairs. Her son was so kind and he regularly came to my room and asked me whether I needed help. He got his medical degree from University of Maryland and as a resident doctor at Hopkins. I was lucky with medical helps.
2
Growing up in this city in the 80s-90s people sleeping on the sidewalk was a very common sight, especially in the Lower East Side (LES). I'd often just check if the person was breathing, visually, and if the rate were dangerously low I'd just ask 'em " you alright man?" I'd always get a blank stare or lethargic affirmative of some kind through pinpoint pupils. Satisfied they were maintaining an airway I'd leave them alone. Now I find far too many "good Samaritans" of the "just moved to New York" variety are quick to call 911 without even speaking to the person. This fills my ER with homeless people who have NO BUSINESS BEING THERE!!! Wasting time and resources when a chart must be created, EMS transport is wasted, and the patient is discharged within 20 minutes. All because someone, not intoxicated or under the influence, was sleeping on a bench and some dingbat from middle America didn't have the courage to just ask, or leave well enough alone.
2
Decades ago, I worked as a LIIRR conductor. When I was not working on a train I would have down time to amuse myself. In the spring I would go to the Brooklyn Botanical Gardens and nap on one of the benches. I would be sleeping and I would hear the teachers chaperoning their children to be very quiet so as not to wake up the homeless man.
During the same era homelessness was rampart in NYC. I was feeling particularly guilty one day. As I was walking down a street seeing what I thought was a homeless person begging with a paper cup I reach into my pocket a and grab a handful of change. I placed the change in the man's cup.
I continue walking down the street with sense of pride in my charity. The man yells out, "Hey Mister that was my soup "
The point I am trying to make is you really can't tell what a person is feeling in NYC. LET SLEEPING DOGS LIE.
This era's opioid problem is small potatoes to heroin problem of my youth and Crack epidemic of the 1980's
2
It is significantly worse than the 80’s. 65,000 a YEAR were not overdosing and dying in the 80’s.
5
There's really very little we can do for the people who have reached the point of shooting up on park benches. If we want to save lives we need to focus on keeping the next generation from falling into that horrific trap. That is the crisis we need to address, by stopping it before it starts.
The crisis, the emergency demanding attention, does not happen when we pass the man dying of a drug overdose on the street. The crisis happens when that man is a teenager, being introduced to drugs, by a person we don't know, in a place we don't see.
1
Thanks for that broadly applicable cobblestone analogy.
6
Dr. Ofri sounds like someone who just got a hammer and is now searching vigilantly for a nail that needs a good pounding.
She certainly seems well-intentioned, albeit terribly naive. In my experience, those who are addicted to opiates are seldom devoted readers. That should have been a clue.
Naloxone does not just awaken the addict, it will put them into full-blown withdrawal; they will not be grateful. Attacking the "rescuer" is not uncommon.
I worry about the doctor's presumptiveness in assuming that the book-reader on the bench is an addict, not just someone who nodded off in the sunshine. Even if drug use is the cause, why is she assuming opiates? (Other than the fact that she has that naloxone waiting to be used, of course.) If Dr. Ofri took the time to learn about drug abuse, she would know that the streets are a veritable pharmacopeia. The situation she describes could result from many things; haloperidol, benzos, lorazepam, strong marijuana, alcohol, or some combination. The individual could be using a prescribed medication, or perhaps he was up all night for some reason. In any of these situations, naloxone is NOT indicated.
Stop carrying naloxone doctor.
10
I'm afraid my cynicism overcomes my desire to do good in situations like these. Individuals who choose to inject themselves with heroin or similar are making a conscious decision to check out (very rarely is someone forced at gunpoint to take that very first injection). To give someone narcan just so they can repeat the process again, multiple times over in many cases, seems to be a waste of time and resources. I believe narcan belongs in hospitals only, and not anywhere else. Callous perhaps, but many folks don't wish to be 'saved'.
4
Haven't you answered your own question simply by carrying the naxolone kit on your person? Why else would you have it?
1
I haven't much time for the author's hand wringing. Narcan is widely and freely available to the public here in Indiana. People without medical training make the decision to see if assistance seems to be needed many times a day. Some of them have not even taken the free training about using Narcan.
3
"I can’t possibly shake the shoulder and assess the vital signs of every seemingly sleeping person I pass on the street." Well no, of course not. Especially in a city like New York you can't possibly know who is just sleeping, who is drunk, who is mentally ill, or who might be actually overdosing. The problem is not the responsibility of individual doctors going about their private business; it's the government and the community's responsibility to take care of the most vulnerable. And as noble as your compassionate urge is, some people don't want to be helped, and they also have privacy rights that need to be respected.
5
"... it's ... the community's responsibibility"
But who is "the community"? If you can't put a name (or list of names) to the task, then no one is responsible.
3
I am a retired Trauma nurse... I feel a moral obligation to help out my fellow man. I stop many times. I have never regretted it. Twice I stopped and performed CPR; both patients lived. Once I .. and another homeless person held pressure on a bleeding artery until HELP arrived. I think a good answer to "would you stop" is... what if the roles were reversed.. What if it were you, your child, your Mother.
15
The more someone touts their own compassionate efforts, the more I doubt their motivation. Yes, we should all notice and reach out to strangers who may be in trouble. But do we need to tell everyone we did so? How many times have we seen the “compassionate act” Instagram or Facebook post gone viral? And the follow-up stories on TV or print news?
It’s everyone’s responsibility to look out for others. No need to announce it when you do the right thing.
7
In other countries methadone clinics and treatment centers are far more accessible. But should that fail to work, heroin in measured doses and clean needles are dispensed without giving people/patients/"addicts" a hard time about a difficult problem. They go on about their daily activities just like every one else. This is not the same as alcohol intoxication and it doesn't cause cancer like cigarettes, so what is the big deal? Can we grow up and try a different approach? I don't advocate smoking really potent marijuana and driving or going to work, but if you're at home in front of the stereo listening to John Coltrane (or AC/DC), that is JUST FINE as well. Some drugs ARE dangerous, especially with continued use, but opioids in moderation are, in many cases, better than a whole lot of other substances whether they're controlled or not. Doctors should be advocating a sensible set of laws first, and second- access to places that offer shelter and support. And not everyone wants or needs to seek the help of a church.
5
Given: The American Medical Association has a code of ethics.
I had an experience in October, 2017 with an Emergency Room doctor at the San Francisco VA Hospital. I was treated for a food borne illness which was caused by tainted meat that I purchased at a local meat market. I brought with me a large sample of vomitus from a night of throwing up my entire stomach contents. I also suffered an immediate condition (upon waking up within hours of barbecuing the contaminated meat) referred to by doctors as paraplegia (paralysis of both legs). I called the Nurses' Aide line at the hospital and was told to get into the Emergency Room ASAP.
My neighbor helped me downstairs from my apartment to his car because I could not walk on my own. I asked him to bring with us a large sample bag of vomitus because I thought it might be useful to identify the cause of my food borne illness and possibly direct my treatment. I entered the hospital in a wheelchair.
The admitting nurse wrote in the medical notes: "Patient thinks that he has a food borne illness." My neighbor was told by the admitting nurse to throw away the vomitus bag in a proper disposal container. She did not consult a doctor.
The Emergency Room doctor described in the medical notes my condition of not being able to stand as a "walking problem" and did not not report my food borne illness to local health authorities as required by law.
Now, I do not have a legal case against the market that sold me the tainted meat.
5
There are no right answers, nor right instant formulas.
As much as we would like to think that one answer would provide a universal solution. Each situation is unique in many ways.
It is also not about feeling good as a 'Good' Samaritan, nor is it about a teaching lesson for a child. There are endless opportunities to teach a child.
It is about the person in need--and the appropriate response to that person's presumed need.
Just as a physician can notice a pathological clinical sign on a person at Starbuck's or other public location. Do you interrupt that person and discuss their medical diagnosis?
One cannot be a physician 24/7. It is often too easy to do harm, as it is to do good. That's why Hippocrates cautioned that "above all do no harm." To carry Narcan is like someone carrying a hammer...looking for a nail to hit. There are many reasons someone may not be conscious. Besides sleep, there are other reasonable possibilities, that require different solutions.
We can however be human 24/7. No man is an island unto himself.
Each person has a comfort level that can sometimes be challenged. Does an individual who cannot swim go in a nearby pool or waterway to save another who is drowning?
The Thai Seal Scuba diver who miscalculated his oxygen tank is both sad and regrettable, and a cautionary tale about miscalculation. There are no simple answers.
4
Two thoughts:
If a doctor is out and about carrying a medical kit that might be used then there ought to be some thought and planning around when and how to use the kit.
Secondly, it seems like this all really boils down to how we as citizens care about our fellow citizens. People don’t walk around not asking about the condition of someone who seems to be in crisis or suffering because it’s wrong or bad but because they are afraid of looking a fool. Give up the social anxiety and just care a bit more. Be a stand for care, the rest will follow.
4
I commend the doctor and I caution all those who say it’s best to call 911. Here in Seattle, we have a huge problem with drug use out in the open. I’ve approached the police while walking my dogs more than once to point out somebody slumped over or swaying and listing with a needle stuck in the arm and have been turned away with a curt “they’re high.” I’m horrified by this response. We are all diminished by this abject suffering and all these protocols, laws and liabilities have hardened are hearts and turned our cities into feast during a plague scenes out of some medieval painting. It’s all mind your own business and keep your eyes glued to your smart phone. This is not progress.
7
It is progress though, because in the past that cop wouldn't have shrugged it off, they would have arrested and incarcerated the person, and ruined what was left of their life. Even indifference is preferable to what went on under the War on Drugs. And the fact is, police and hospitals are overwhelmed with the endless cycle of drug problems and focus on the most urgent cases, leaving few resources for run of the mill users.
1
Every thinking person experiences the quandary: you can't help everyone that needs help. People reading this have resolved the internal dissonance one way or another, otherwise they would be lost down the rabbit hole and likely in need of help themselves.
5
They lose their rental unit. Then turn to or continue with drugs, possibly after being cut off from prescription drugs.
Good rule for living a humane life:
Never resist the impulse to do the right thing.
5
"Good rule for living a humane life:"
But a very bad rule for staying out of trouble...
2
Sometimes I wonder if 'helping them' wouldn't mean to let them peacefully slip away in their coma... It's a shocking thought at first, but if you think it through it becomes less so, I find.
4
You might find some comfort in the knowledge that department heads at major medical centers contemplate the same things.
How much, for example, would you save if you allowed those suffering from severe and persistent symptoms of schizophrenia to quietly "slip away" in their delusions?
Your insight has the potential to transform American medicine.
Surely we would all take comfort in such a thought.
I have a close relative with schizophrenia. She takes medication to help control her symptoms. She works and lives on her own. I love this person and I am glad she is on this Earth. Thank God it is not up to any doctor or bureaucrat whether she lives or dies.
oogada,
No, you couldn’t be more wrong. You are doing hospital medical ethics boards a disservice. They do their best to balance quality of life decisions while taking into consideration the risk versus benefit of treatments for patients. No one treats these decisions lightly.
The only ones in the business of denying services are insurers. Just today I received a refusal to compensate my doctor for a test he feels is medically necessary for assessing my response to treatment, the insurer considers it experimental. It is not. My doctor performed the test knowing he would likely be refused reimbursement. He chooses to do this test for every patient whether or not he is compensated. His practice absorbs the cost.
1
I agree. If you can save someone's life, you should do it. It's an ethical obligation. (p.s. I'm NOT necessarily referring to embryos and fetuses.) Narcan should be easily, publicly available all over the place, like fire extinguishers, portable heart defibrillators, and fire hydrants. Municipalities should consider spending the money on this stuff.
1
"If you can save someone's life, you should do it."
You apparently believe that every human being is inherently good and capable of doing good in his/her future life.
If you consider this carefully, or read the newspapers, you will find that this is absolutely not true.
If you save somebody's life, you may be saving a beloved relative, or a future Nobel winner, or someone who will go on to rape or to kill.
You have no way of knowing, and no way of selecting, but saving someone's life is not always an absolute good.
2
I am actually quite concerned about everyday citizens thinking they can save someone from an opiate overdose because they now carry a drug with them that can reverse the effects. One, it potentially puts people in danger--you don't know how someone is going to react when you try to approach them, whether they're not on some combination of drugs that could make them violent, etc. Two, the general public does not have a medical degree. This person was able to assess the situation and concluded that the person was sleeping--there are plenty of people who might not have and might forcibly try to give this person what they believe to be a "life-saving" dose. My husband works at the hospital and the number of people who are brought in simply because they are hung-over or sleeping and people thought they might have had a concussion or something else traumatic is incredibly high. They get CT scans, they get all the works, because if someone is found "down," they might have hit their head and doctors must be sure before they rule anything out. Most of these people are homeless, CT scans and the rest of the hospital visit are not cheap--the rest of us are paying for these visits. I don't think it's a good idea to advertise to the general public that they should be diagnosing and administering medical treatment when they are not at all equipped to do so.
6
I am a doctor and I would never check on someone like this.
I have in the past answered a few times when people have asked "is anyone a doctor?" I have gotten appreciation and thanks, and I have gotten no thanks and an attitude back at me.
I don't care what any ethics statement says. It's not my problem. I don't care.
7
Interesting that now that the doctor is able to carry the naloxone, every sleeping person looks like an opioid overdose sufferer. Have a hammer, everything is a nail. Once the doc has carried the naloxone for awhile, that feeling of high alert will settle down and I'll bet the doc will be able to tell more quickly what is the state of each person she encounters. I sympathize with her for having to make the call about whether her daughter might be at risk. She can explain her thinking to her daughter, appropriate to her age, and that will help. ("I think this man is asleep, so I won't bother him." "Uh oh, honey, I think this man might need my help. Stay close by but not right next to me while I check.") We all make these calls in our own way (whether to engage, whether to give money or food). It will get easier with more experience.
3
Well no - she is simply developing a Bayesian model - surveys suggest between 50% to 80% of street people are abusing drugs - so she develops an hypothesis and attempts to verify it with additional data
We are all Bayesian machines.
4
How often, as parents. are we blessed with the opportunity to show our children the possibilities of conducting the professional and business portions of our lives with compassion while demonstrating the technical and professional skills we possess?
I was struck, more like humbled, by the opportunities Dr. Ofri created by her kindness and her professionalism: to educate her 12 year old about the need of the physician to act with both empathy and professionalism and to show her child that the physician's professional skills are never only reserved for those who come to her clinic for examination, diagnosis, and treatment.
Those moments in which parents can teach their children through demonstration and where the children actually are engaged, through observation of their parent's humanity, are moments that parents aspire to and live for. Dr. Ofri reminds us indirectly that the best of such opportunities rarely if ever planned in advance, but are opportunities bestowed by chance and ones that we have to be ready to take even as they arise during routine, often mundane activities like walking home from the subway station.
Can you imagine, just for a moment, the questions the child had for her mother, who she observed as the Doctor at work? Can you imagine the feeling Dr. Ofri must have had later to have been given the opportunity to explain the importance of compassion, alertness, and taking action when required. Socrates would have pined for the opportunity.
7
What is the responsibility of individuals, not demented by other noxae, knowing, for example, in this day and age, of the disastrous effects of the uncontrolled nonmedical use of opioids, not to initiate, or to discontinue, their use?
I think Dr. Ofri’s hesitation was out of concern for the impact the situation could have on her 12 year old child. If the person became combative as often happens with ODs, would her child be injured? Fortunately, all was well.
The decision to render aid can be difficult, Good Samaritan Laws may not extend protection to nurses, doctors and other healthcare professionals. We are restricted in the type of care we can render as defined by our states Scope of Practice Statues. This is made more difficult by the fact that what is allowed differs state by state. If one holds multiple licenses the Scope of Practice statues might contradict each other.
This is the ugly truth medical professionals face each time they decide to stop and render aid. By sheer luck I never found myself in an off-duty situation that was beyond my scope of practice.
The following resource demonstrates that only 42 states have naloxone laws and 32 states have 9-1-1 Good Samaritan laws.
www.drugpolicy.org/resource/which-states-have-911-good-samaritan-laws-an...
6
Correction: statute not “statues”
When I see people on the street like that, I wish that I were a doctor so that I could help. So it is disappointing to read about someone who has the privilege of being a doctor but is not eager to use her skills to help others in need.
1
See my comment below. As a physician, I think your comment is off base. There are many reasons a person may have altered consciousness. It is a judgement call, but calling paramedics is one way to narrow the differential and help ensure that useful help is provided. They can check vital signs, give narcan, give glucose if there is a possibility of hypoglycemia, etc., etc.
6
To echo Bill's comment: If you WERE a doctor, you would be much less likely to intervene, and much more likely to understand that very often the best use of our skills is often to stay back and "First, do no harm."
2
There is a large differential diagnosis for the cause of the man's altered consciousness (in addition to narcotics: stroke, diabetic ketoacidosis, overdose of non-narcotic medications, etc., etc.). Best to call 911 and wait until paramedics arrive.
9
You think people should call 911 every time they see a homeless person sleeping or slumped over? Even if that were justified, which it clearly isn't, there's no way 911 would take you seriously when you keep calling to report sleeping homeless people. Do you think that first responders have no idea that New York is at all times literally filled with homeless people in various states of consciouness?
"Their numbers are increasing, as the surge of opiate addiction meets the surge in housing prices."
So, are they selling their homes and buying more drugs, or, are the drug dealers making huge profits and driving up the cost of housing?
I'm not the only reader disappointed by this statement. How does the good Dr. explain the opiate crisis in small tons a d cities (e.g. Marion, OH) where housing prices are flat or even declining?
The truth is there is despair everywhere, not just on the sidewalks of NYC. And, before anyone becomes exercised, all of this predates Trump.
If anything this piece reminds us that physicians used to spent a large portion of their time in the communities they served making house calls and checking in on patients. While this model is archaic and impractical today, there is a lesson to be learned. The point-of-care for non-emergency situations needs to meet patients where they are at. This is improving with telehealth and mobile health, but is a long way from a good physician seeing a patient in their natural habitat. Dr. Ofri did have an obligation to check on this person, but this could have been in the form of a 911 call for safety and back-up.
2
You don't know if the publicly slumbering person will react angrily or violently if you approach them. You are putting yourself and child in danger. Call 911 unless it's obvious that he is in no condition to lash out at you. You're not in Bellevue, you're on the street.
12
If you call 911 there's a decent chance they will send the police, who will simply harass the person and make them leave, or else arrest them. You won't be doing them any favors. But more likely the operator will say "A sleeping homeless person? In New York? Good heavens, what an emergency, thank you so, so much for letting us know!"
Wrong. Calling 911 for a sleeping person is a tremendous waste of resources. If you are afraid to just look to see if someone is breathing, then just walk away. You're not part of the solution, you're part of the problem.
Thanks to lawyers, any responsibility a doctor might have to help those in need has been eviscerated. No physician dare help a stranger, because of a legitimate fear that the actions can lead to a lawsuit. But this is only a minor example of what our sue-crazed culture has wrought. Doctors are increasingly hesitant to treat complicated patients, because if anything goes wrong, those patients (or their families) can (and often will) sue. The fact that risks are disclosed, and the reality that medicine is not a perfect science and complications can arise (especially from surgery) is no shield against frivolous lawsuits. Patients still try to stick it to those "rich" doctors, even when they are fully aware of risks and agree to a given treatment.
Let that sink in. When you're older, with thinning skin, longer healing time, pumped full of medications like blood thinners, and need to have a tumor removed near the nerve that controls your arm (for example), why would any doctor treat you? You could bleed out, get an infection, or the nerve could be accidentally damaged. All of these risks are common, but for some reason a patient can still sue (and win!) because something went wrong.
For some reason, many companies can make us sign away our rights and force their customers into arbitration, but not physicians. Nope, the very profession that we all desperately need is most subject to frivolous litigation. So perhaps the better questions is: what is our responsibility to doctors?
12
If you were the one who suffered ill effects, damage, etc. as the result of medical actions, I seriously doubt that you would consider litigation designed to compensate you fairly for that to be "frivolous". It's a matter of perspective. You blame lawyers, but lawyers are only representing clients. And it's juries of ordinary citizens, not lawyers, who award damages to plaintiffs.
3
I am a physician. I and many of my colleagues have intervened in situations on the street or airplanes, from just checking on someone like Dr. Ofri did to performing CPR until EMS get there with narcan. We are fortunately protected in these situations by Good Samaritan laws. No one I know would shy away out of concern for liability.
9
As my name announces, I am a lawyer, a mama, and I live in Buffalo. I was going to comment on this article anyway, but I had to address your claim that it's all lawyers' fault.
1. There are laws that cover Good Samaritans who render aid in emergency situations, so they face limited, if any, liability. This is to encourage us to help each other if possible.
2. Medical Malpractice is highly 'regulated' and many avenues for relief have been limited, and awards capped. Already.
3. Your gripe is more general, so I'm going to comment elsewhere about the morality of the situation, which is kind of the point this good doctor was trying to make.
3
I have read 2 stories about people who were behaving oddly in public. The authorities assumed that they were drunk and took them to jail, where they died. Their behavior was due to illness, not drunkenness. One of the incidents happened in a small southern town and was based on southern bigotry, but the other happened in enlightened Sweden.
So nowadays, apparently, people seeing odd symptoms think "opioid addiction"
5
I’m pretty sure the oath didn’t have in mind to jeopardize two lives (yours and your child’s) to help a complete stranger who may or may not be in a chemically-chemically induced state.
15
One summer before the opiod epidemic I witnessed a man lying stretched out on the pavement across the street from a liquor store. Being a small woman I was afraid to arouse him....I observed from a safe distance...observed no sign of life and called 911. They quizzed me and I explained my concerns of arousing someone. This was before they sent along fire trucks etc. I watched...the ambulance arrived...aroused the poor soul while they poured out his precious bottle of hooch which obviously just purchased! I felt very sorry for that and no I did not bounce over and give him the bucks for another. There was a full service supermarket next door to the liquor store...that was the way they set it up at that time.
3
A big problem for the homeless is how to spend their day. I sat across from a homeless man in the library one day. Every time he nodded off in front of his books, the guard IMO rudely awakened him and told him he would have to leave. (it was a hot day.)
People need shelter both day and nite. How can we be more humane? (And why is Pfizer raising drug prices?)
I pass at least one or as many as six beggars in a 13 block walk. (Familiar and new ones. The white woman seems to be on vacation?) How much can/should I give? One man sleeping on the sidewalk one day refused the 1$!)
8
Geez people, get a grip. It's just a mental commentary on a moment in time. Nobody was failed, no sacred duty neglected. Should nothing interesting ever be written lest the thought police swoop in?
15
It is worth noting, that there is some physical risk to the person administering the narcan. People don't necessarily know that they have over dosed themselves. The effect of the narcan is thankfully rapid, but also very jarring to the person who from their perspective, might have been interrupted from the fleeting pleasure of their hard-earned respite from an otherwise-crappy existence. They may not be grateful, they may be angry, they may be violent. Be prepared for it.
21
Now we're under the obligation to come to the aid of junkies on the street?
No, no thanks......
9
Uh, how do you know that someone who is unconscious on the street is a junkie? May they are diabetic or had a heart attack or had a seizure or are simply asleep etc, etc, etc. Better hope anyone who might find you unconscious doesn't have the same callous disregard for the welfare of a fellow human being but, rather feel "the obligation" to come to their aid. Read Luke 10:25-37, the parable of the good Samaritan, then reconsider your stance.
2
I read it, I've not reconsidered.
I've worked in many developing countries. In some places every corner of every street with a stop sign is populated by beggars who are hungry, probably sick, and extremely poor. Five US dollars would make a huge difference in their situation. But my resources are limited.
Going home after work in Los Angeles I step around people on the sidewalk who are very needy. Sometimes I give them a buck, sometimes not.
We all face dilemmas about giving and helping people in need whether its money, medicine, or expertise.
Wouldn't it be great if humans were more generous and less corruptible? Our governments have the resources to help, but not the will.
9
Question- can Narcan do harm to someone who is NOT overdosing?
1
No, Narcan (naloxone) will have no effect on someone who does not have an opioid in their system.
www.nytimes.com/2018/04/06/us/naloxone-narcan-opioid-overdose.html
1
Intervention that could provoke a sudden violent reaction (as Narcan can), with your daughter by your side, is arguably the wrong ethical choice. A parent's first responsibility is to their children.
7
I'm pretty sure a doctor's first responsibility is to help people at risk of dying, whether or not they have a child with them. I don't think the kid being there gets you off the hook. Would you be ok with a loved one dying because the doctor who was there didn't want his kid to get scared?
Clearly the fellow sleeping is in pain. The good doctor ought to prescribe a pain killer she saw on CNN commercial breaks and then take the free vacation to the Virgin Islands offered by Perdue Pharma. The Grass needs cutting up on Round Hill Road and someone must pay. Plus the Range Rover lease is due. First due no harm. OK. When my 15 year old son awoke from minor surgery at Yale, while still groggy his doctor filled his overnight bag with Vicaden. Thanks, doc. I threw them in the garbage, he removed them. Next.
1
Your child and all of us can learn valuable lessons from people like (you) Dr. Ofri. When you swear an oath, you are forever bound by it. The view is best from the moral high ground.
6
Arousing an addict from an overdose can be a dangerous thing. Spraying a chemical into the nostril of a deeply sleeping psychotic homeless person can also be fraught with peril.
I have responded to true and certain emergencies in an airport when asked to see a person with cardiac arrest and a neighbor in shock from a vasodilator drug.
But I do not walk the streets looking to intervene.
16
Many of these people who comment have NO idea the numbers of people in cities you come across who are strung out on drugs or who have possibly overdosed. The judgement passed here is ridiculous.
You have to look at the person and make the best judgement you can.
I know *I* would hesitate if my child were with me, medical training or no. My primary responsibility is to keep my kid safe.
Often in the Hollywood area of Los Angeles we come across people who are hallucinating and these people can sometimes be dangerous. If they are carrying a knife and get angry or decide you’re a threat you are on your own.
Once I walked to get a donut with a friend and a young man was sprawled out, naked on the sidewalk. I decided to call 911 and the firefighters who responded reprimanded me. After they left my friend and I got the man to sit in the shade and gave him water. Another time my husband and I came across a guy in a hospital gown who had been dumped out of an ambulance in Chino Hills. We helped him call a friend and drove him to the friend’s house. But sometimes I have calculated the risk to my own safety and decided it was not worth it.
29
As a NYC*EMS paramedic through the 1990s, and a physician now, I can only shake my head in amazement.
Any physician knows that once you have a piece of equipment, you have an obligation to maintain it, to maintain your training and proficiency in using it, and to use it properly should the need arise.
This becomes relevant in situations such as deciding what to buy and keep in a particular medical office - if you have a defibrillator, you have to know how to use it, and to actually use it, and if you mess up, you can be sued.
The converse is that if you do not have a piece of equipment, you have no obligation to use it.
In this case, I would never in a million years carry Narcan with me, because if I did, I, like Dr. Ofri, I would need to make this same calculation repeatedly every day while walking down the street.
I may have an obligation to help my fellow man, but I do not have an obligation to help every single one of my fellow men.
I will also note that all of us in EMS hold a special deep hatred for "good Samaritans" who call us for perfectly ordinary drunks and bums who are sleeping, or just sitting, on the sidewalk and minding their own business, like the rest of us should be. If you are worried call 911, and then LEAVE as soon as they arrive, and let them do their job (which may be to leave the person right where they are, and where they want to be).
Expressing what I think of people who use heroin would violate the NYT's standards...
10
No, Narcan/naloxone blocks the opioid receptors in the brain, effectively pushing the opiate off the receptor. If there aren't opiates around, it has no effect.
1
If this were our son or daughter or loved one--Would there be a question? What would you want to be done? At the very least, there is no decision about whether to call the trained city personnel that are supposed to be helping the addicted and mentally ill to get off the streets and into treatment.
And when they fail to show--because they likely won't--write about that, hold them accountable, and speak about the enormity of the failure of our significant tax dollar spend.
2
Oh Dr Ofri, Didn't you get the memo? Medical care in the United States isn't a right, it's a privilege. You neglected to do the first imperative of the American healthcare system: biopsy the wallet.
9
Do what ever you can to help within legal bounds. You were trained to do so and took an oath. Trust your judgement. If you are wrong well M.D.s are human too.
2
I find it interesting that this doctor walks around with a vial of Noloxone...but is not carrying a bottle of Lidocaine, dilantin, glucagon, nitrogycerine, desmopressin, or a dozen other meds that can save lives if sombody suffers a medical catastrophe in public. This is the typical NY virtue signalling. Only the illnesses of the socially less responsible (though no less unfortunate) are of concern to her. Think about i!
8
Compassion. Try it. Include empathy as well.
13
Oh man, really? Might she be carrying Noloxone because, um, there's an opioid overdose crisis in this country? Well, many people chose diabetes over health, so...if thousands of diabetic people were being found dead in parks from an overdose of insulin, I guess saving them would be 'virtue signalling for less responsible'? Shorter James: If the author can't treat everyone, she's worthy of my contempt for doing anything.
9
I have no contempt. I just wonder about the way the liberal mind works. I work in an emergency room - despite the opiod overdose "epidemic" there are still far more people dying of other treatable causes on the street. I think if she is going to take her breast beating to its logical conclusion, she should carry a medicine chest on her back and a defibrillator on her belt.
People inject, snort, dose, and use other means of introducing (unknown) substances into their bodies. What is the individual citizen's responsibility to intervene in these cases? Perhaps it is less than some might think. I have heard of cases where users of opiates have been "brought back" multiple times from the brink by the use of naloxone. What is the requisite number of times I wonder. Two, three, four, one hundred? Perhaps there is something to the old thesis of taking personal responsibility for one's actions. I'd be interested in hearing other people's thoughts on this..
4
Personal responsibility for one's actions should be taught from a very young age. Sad that this is not the focus when talking to people about drug, and alcohol addictions. Sad, that so many people feel so helpless, that the fix is the most important urge.
Let's be proactive in preventing these sad incidents and loss of life. Tell our young people that there are always consequences to our actions. Sadly, we are failing them.
I wonder about the first responders who have responded to overdose calls repeatedly for the same persons.
Dr. Ofri, I am always amazed at the ability of physicians to take in so much information about humans with a quick observation. In my experience their power to observe is exceeded only by their capacity to care about their patients. Your concern and your naloxone are sorely needed in our society.
27
Many doctors and non-doctors alike help people like this all the time every day in the United States. Many don't as well. My praises to you Dr. Ofri. You set a very good example for your daughter and all of us.
Now as a society and medical profession, we need to not just carry Naloxone with us to save the one "drowning" person, we need to walk up-stream to find out why people are jumping into the river in the first place, and attempt to change that.
28
This interesting vignette corresponds to the argument of who are the "deserving poor". There are no quick or easy answers to these questions and most people are uninterested in finding solutions to them. The people who experience homelessness and addiction are "other". This is who we are.
6
I am humbled by your thoughtfulness and care. You put aside your doubt and gently thought about your options. To go this far in your thought process for a stranger is to be recognized. The medical community does not always get my admiration.
11
Some decades ago, I read a short article called, "Better Dope," which advocated producing safer recreational drugs. One of the effects of the "drug war" is that businesses did not make such investments. Dr. Danielle Ofri is describing some of negative externalities of the the drug war.
7
Thank you. No law has ever stopped someone from using a drug that provides relief from pain. No law has ever kept people from selling some version (always overpriced) of a drug that blocks pain receptors in the brain.
Sadly, what makes those drugs so dangerous is the uncertainty of their strength and the contaminates they contain. Nevertheless, they remain highly desirable and extremely profitable.
People in pain are desperate to escape it. Just because others cannot see the source of the injury (be it emotional or physical) it is still very real to the victim. Making narcotics difficult to obtain simply makes them more profitable and dangerous. Drug laws are as much a failure as Prohibition was 90 years ago. America will continue to see overdose deaths skyrocket until we stop trying to control human nature with useless, randomly enforced laws and pious, empty rhetoric.
2
Very thoughtful piece. A little attention to detail in cases like this go a long way to saving lives, and ourselves. Looking the other way versus seeing the book. We should all remain vigilant and prepared to react, no matter our toolbox.
1
As a Georgetown medical student working a shift at the now defunct D.C. General Hospital back in the 1970s my team was called to Emergency to evaluate a large, burly man with suspected narcotic overdose. The intern on the team was a very bright, bespectacled and energetic young man who was about 5 ft 6 in tall and weighed less than 150 lbs. The precursor to naloxone, a drug called naltrexone, had recently become available for injection. The intern injected a dose into the patient’s intravenous line and nearly instantly the man woke up and when informed what had happened promptly jumped off the gurney and punched the intern in the face breaking his glasses and bloodying his nose. Apparently he was livid that we had ruined the high from his last $10 bag of heroin. Sometimes, no good deed goes unpunished.
34
Not obvious to whom? The author wrote about how she went about making a judgment-- which seems like something most adults could do.
First Aid and CPR don't require a medical degree, and anyone with an interest in helping their fellow humans can learn enough to assess respiration, smell for alcohol, and look for drug paraphernalia. If they don't carry Narcan, they can at least call 911.
And reading the news regularly renders it obvious that many people are suffering from opioid addiction and possible OD, and that someone could literally be dying in front of you.
What's not obvious?
Lovely writing and the author's compassion and caring shone through. It made me go back to see the name and I was not surprised that the doctor is a woman. After 50 years as a nurse, I simply cannot imagine this being written by a male doctor.
The large scale admission of women into medicine has been a huge boon for the caring part of medicine although a loss for nursing, the original caring profession.
16
This is truly sad. It is easy to counter with examples, e.g., Albert Schweitzer and thousands more.
One would hope that people today would not be judged by their gender (or "color of their skin"), but by the content of their character.
By the way, what do you think of men entering nursing? Are they destroying "the original caring profession"?
11
As a female physician, I didn't attribute a specific gender to the author of this article. Didn't even occur to me. And it's somewhat sad that you 'cannot imagine' that it could be written by a man.
6
Fifty years a nurse is all the experience I needed. Care vs. cure.
As to Schweitzer, one man does not a profession make. And, he did the doctor stuff - suturing wounds and the nurses cared for the patients. Still, he was criticized for his paternalism. "Schweitzer was nonetheless still sometimes accused of being paternalistic, colonialist and racist in his attitude towards Africans, and in some ways his views did differ from that of many liberals and other critics of colonialism.[57]"
I stand by my statement: the massive entrance of women into medicine has been a huge boon to our society. Some of the men going into nursing are truly caring individuals, but many like some of the women entering these days, want a well-paying, secure job. And a lot of the men go into the adrenalin areas like the ED.
1
Sadly, medicine has morphed during my tenure from a call to service to a trade. "Patient satisfaction" has replaced care and healing.
Dr. Ofri's actions and true ethical concerns snap us back where we should have stayed all along.
I would encourage all who would claim they would be "off duty" and walk on by to re-read the social gospel of Matthew chapter 25..."in as much as ye did it not to the least of these, ye did it not to me."
4
According to many firefighters, some addicts revived with Narcan are angry that their high has been taken from them, even as they are brought back from the verge of death. Whatever her future decisions, caution for her child and herself may be a factor.
18
In my opinion, everyone has the ethical obligation to do something if someone is overdosed, e.g. call 911. I look at people the same way she does, even though I don't carry Naloxone (yet) and I'm not a doctor. However, I wouldn't expect anyone to interfere with sleeping people just because they are high or might possibly have overdosed. There need to be obvious signs. I even find it confusing that this physician thinks pinned pupils necessarily mean the person has overdosed. Pupils always pin when someone is high on heroin. The bottom line is, if there are no obvious signs like respiratory distress or bluing lips, doctors and the rest of us are free to go about our day and, if a person is indeed high, hope and/or pray for them, donate to organizations fighting for them, volunteer time to organized efforts to help them and their families but a doctor waking them is probably not pragmatic, helpful or needed if there are no obvious signs of overdose.
7
How can you tell the difference between someone being high and someone in critical danger if you don't stop and look and probably move near them?
Use the Narcan, even if it's a case of mistaken identity. Big Pharma needs more profits!
1
I can understand that you think it's heroic that you carry Narcam and are on your toes ever the vigilant person wanting to be that hero. But, what happens when you use it on the wrong person. Maybe that person has a serious medical condition and is on strong pain management in the form of Morphine. They received this prescription legally through a pain management doctor and are NOT abusing it. And say that, that person happens to be dozing on the bench of the train and doesn't respond right away to you shaking their shoulder or they come out of it in a deep stupid stupor perhaps unable to answer your questions because of the medicine. Perhaps their breathing is slower than a normal person and their heart rate higher. Are you just going to Assume that that person is an Addict like they are probably already stigmatized because they are treated with pain management and shove that Narcam up their nose already assuming that you are doing the right thing. I ask you to consider this scenario because it happened to me. A nurse assumed I had overdosed as I dozed on the bus ride home and without asking gave me Narcam which causes you to go into immediate withdrawals, the pain that I was already in intensified to a degree I can not begin to describe. It was horrible, and the worst part is I had to wait until the Narcam left my system which took hours. The nurse profusely apologized for her mistake but her apologies did nothing as I was taken to the E.R for her mistake.
3
I was an EMT for several years. We were trained and told that we have a legal, not just ethical, obligation to help ailing strangers in an emergency. We were warned that if we did indeed fail to stop and help we could be held legally responsible. After a bit of experience it's not too difficult to assess a person from a distance to determine if they are in a medical emergency. Fortunately most states, if not all, have good Samaritan laws that protect people who stop to help strangers. But once you stop to help a person in medical distress you have to stay with them until more competent help arrives, like an ambulance or family member who will assume responsibility for the person.
I'm kind of puzzled by this article. Why would a physician carry naloxone unless she intended to use it? Why is she mulling over such a dilemma? Why did she even go to medical school?
23
In many states trained medical personnel are not protected by Good Samaritan laws.
39
Aristotle,
In NYS, if you are a volunteer EMT, you have a duty to act all the time, as you work for free, but id you are a paid EMT, you have a duty to act only while you are on the clock.
2
Interesting points. There is no legal obligation for physicians to help someone in public who is not their patient. It may be the right thing to do but once a physician decides to intervene (whether individually or as part of a team) s/he has to remain with the patient until (as you stated) the patient is transferred to a higher level of care. If the physician determines that there is a medical need, then releasing the patient to the family is inadequate and incorrect. The best thing to do is call an ambulance and remain with the patient until it arrives.
As an EMT, you are probably better at spotting medical emergencies from a distance than us doctors. Many medical crises are not that obvious. I recall a case several years ago while I was in a cafe. One waiter who knew me said that his colleague was suffering from an excruciating headache and intermittent leg numbness that started earlier in the day. I asked her two key questions: "do you smoke?" and "do you take birth control?" She replied positively to both. I told her manager that I was taking her to the ER out of an abundance of caution. It turned out the she had a stroke brewing which was nipped at the bud and she left the hospital after three days. She told me later that she gave up both cigarettes and birth control.
Samaritan laws can help health care professionals in some states. There is no liability, however, for walking by. There is liability for helping and doing your best if one does not have legal protection.
2
Is it really an emergency if it's not obvious that it's an emergency?
13
Seriously??
From a dictionary: a serious, unexpected, and often dangerous situation requiring immediate action
Says nothing about whether the situation is “obvious” or not.
10
I have stopped meself numerous times to check on people that do not have obvious signs of a health risk. None (so far) have responded negatively.
I personally think that the best (other than personally checking) is to call 911 or health services. (at the every least) Of course, they would be inundated with calls and the entire system would be taxed beyond proportion, however sometimes to change policy, this can be the only avenue.
Perhaps then there would be more outreach into the community, to get people off the streets and to change drug policy.
Just a thought.
21
In San Francisco the despairing number of people living on the streets has increased and sadly it's not unusual to see bodies lying on the sidewalk and to wonder if the person is alive. I've called our 3-digit help line to request fire/emergency/police come to check things out, I've crept close to confirm the person is breathing, and left food, and a few dollar bills. One time I knelt down by a slumped over man--as did others seeing me move in. His strong alcohol breathe forced me back but I relieved to see he was still alirve. These people are really hurting and it's hard to witness the great numbers of us walking down the street ignoring them.
4
Yes, I usually just ask if they are okay.
Then there is hospital personnel who bring an aging, medically unwell older woman, still in her hospital gown, no shoes and wheel her outside into the cold 30 degree night and leave her curbside. As did happen last winter in Baltimore at the U of Maryland Medical Center.
84
Interesting that Dr. Ofri decided to carry a naloxone kit in her purse but only when seeing a possible need for it does she ".....wonder what my responsibility should be".
Dr. O ......I'm glad that you carry it and decided to check this fellow out. We need more like you.
18
Hey Doc— Better to risk coming off as presumptive and condescending than being a passive bystander to a needless death.
31
What does the ordinary, non-medical person do?
Well, being from New York, I got used to seeing people sleeping on the streets, and even lying in them. New Yorkers just walked right by.
Such was the state of homelessness and joblessness in this "great city."
I did once pass a woman who was obviously in distress, and I stopped to help her. Fortuitously, she was right across the street from St. Vincent's hospital, in Greenwich Village.
I ran across the street to the hospital and told the attendants in the emergency room about her. Incredibly, they refused to leave the hospital to attend to her. I was completely shocked, and to this day I do not understand it.
Another passerby and I helped the woman to her feet and dragged her into the hospital. What happened after that I do not know.
Not all medical personnel have the conscience of this doctor, nor, apparently, even the medical ethics.
139
Not all medical personnel have the conscience of this doctor, nor, apparently, even the medical ethics.
---
You left out the 24x7x365 TV adverts by trial lawyers to "sue, sue, sue" .. that are now beginning to appear in England.
Yeah, we'd like to help. We also don't want to be sued, either, if something goes wrong. And believe me, trial lawyers will glom on you, in a NYC second, I have personally seen it happen.
Waiting for the trial lawyers' association to put that protective caveat in writing. Thanks.
17
There was a case in Chicago in which a teenager was shot by another gang member--right across the street from a hospital. The emergency room attendants refused to do anything and, unfortunately, the boy died.
It was later explained that there's some rule (at least in Illinois) in which emergency personnel are not legally allowed to transport people without an ambulance--and for some reason they couldn't even pull up in an ambulance from across the street. I don't remember the exact logistics but it probably had something to do with lawsuits. The ironic thing was the boy's family did end up suing the hospital and I think they did get a sizeable settlement.
19
I remember that case. The boy was shot in an alley near a hospital that was not a trauma center. The nearest trauma center was about 5 miles away. When hospital staff would not leave their posts to help, his friends borrowed a hospital gurney and pushed him to the hospital that was not equiped to help him and he was transferred by ambulance to the trauma center where he died.
The staff on duty have an obligation to help the people that come to their facility but not to those are a block away in the street. For those people the Chicago Fire Department runs an ambulance service that delivers the person to the nearest hospital with the facilities to provide needed care.
Emergency physicians have a unique role in society. We act daily, many times a shift: to intervene, to save, to interject.
It is more difficult in the world outside the emergency department. Helping a survivor of a motor vehicle crash, giving albuterol to a wheezing swimmer, supporting injured teenage baseball players on the field, providing advice to a coach after a head injury: all of these efforts seem extraordinary but reasonable.
The author's dilemma, and her inquisitive and reflective writing style, presents a modern quandary: when to act when faced with a potential opiate victim.
All of us might face this question, but for emergency physicians, it becomes a more personal and internal decision.
I thank Dr. Ofri for her article, her writing, and her humanity. May we all act to save and intervene when life and humanity requires.
176
My husband is an ER doc. His unfailing willingness to check on anyone he sees experiencing a medically urgent crisis is amazing. After 20 years of shifts lasting sometimes 24 hours or more, he will still raise his hand if someone requests medical help on a plane. He still pulls over to make sure nobody’s hurt if we pass a car accident. I think there’s something different about emergency physicians: they tend to run toward those places we all run from! I’m just forever grateful for their service and wisdom!
164
My 66 year old sister, who has a sleep disorder, fell asleep in her running parked car (with the door unlocked). No kind person, medically trained or otherwise, stopped to check to see if she was ok. Instead, someone called the police and a SWAT team arrived, pounding on her window, yelling and traumatizing her.
Simple checking, asking, compassion, is not an intrusion. It is a human necessity in this fragile thing we call life.
55
I would like people not to be fearful of everyone, but some are - so calling 911 is much better than pretending you do not see. You get an emergency response.
BUT, why in the world would the police approach the car that way? I hope that this was made an issue with the PD involved.
15
They came prepared for whatever might lie ahead and they "pounded" on her window to wake her up if that was possible. What would you have them do first?
5
People are far too quick to cal 911 for the most mundane things. That is terrible advice!
A lesson to be learned. The child of this doctor watched the parent care about someone on the street, down and out, for whatever reason. This child saw an adult take the time, in the midst of busy, busy, hustle bustle NYC, check and see if there was life, near death perhaps, or someone who needed help that could be provided, right there on the street.
We’ve all walked past those street sleepers in NYC, and the author admits if time was taken on the walk home to check out every street sleeping person, one may never get home.
So who is responsible for these souls? The police? The random health care provider? A Good Samaritan? Anyone?
I’m a nurse of many years. I’ve walked right by many times. Thing is, I don’t think much about it, even.
How can that be? What’s become of us? Do we not care? Are we callous? Are we indoctrinated to oh, that’s how it is in the city? Do we just take the scenario for granted in the city life? Is that what we want to teach our kids, that we just walk by?
Well at least for a moment, this child got to see a piece of humanity on the street, a parent’s not only medical knowledge and curiosity, but humanity.
As a teenager, I really wanted to go to Bellevue nursing school, way from Wisconsin. My mother wouldn’t hear of it! Horrors!
But isn’t it good to know a Bellevue doc takes the time to show her child a little medical and humane concern, right out on the street, maybe where healthcare is sometimes needed the most.
75
I agree completely. Dr. Ofri show us what it means to be a caring human being and a caring doctor. She obviously thinks deeply about these things that all of us see every day. Her patients and her students are indeed lucky.
3
You need not be a doctor to intervene. I feel a strong duty as a human to to so, too, though I'm no medical professional and I can't afford the $160 it costs to carry a dose of narcan.
if I see a person on the street in a place or position that doesn't look like they intentionally slept there, I'll try to interact. if they can't, I call paramedics. Once professional help arrives, I walk away.
Sadly, I've done this about 5 times in the last couple years on Seattle streets. I have no idea what happened to the unresponsive folks, but it's important to me to help. if I'm ever in their position, I sure hope someone reaches out in the same way to me.
62
The police, as well as social services, are often very familiar with the individuals who live on the street and may (or may not) have attempted to assist the person in the past. I had an interesting experience here in Seattle. I went to an absent neighbor's house to feed her cat, and a man living in a van parked across the street called out to me. I told my neighbor when she returned, and she said, "oh, that's so-and-so, he and his wife live in that van, they're alcoholics, and they look out for me". Who's helping who? And in my experience, when I have called 9-1-1 to report a person passed out somewhere, emergency services have been responsive.
2