‘There’s No Room in the System’

Photo: Andres Serrano/Courtesy of the Artist and Galerie Nathalie Obadia (Paris & Brussels)

A plan to commit the homeless has little meaning in the ER.

About 3,400 people sleep on the streets or subways of New York each night, and the week after Christmas, EMTs dropped off one of them, a young white woman, at a Brooklyn emergency room. She had overdosed on an assortment of meds and called 911 on herself. Now she was, as the ER psych nurse on duty that night put it, “decompensating” — her mind running the familiar course from okay to unraveled to not coherent at all. The woman was focused on the subject of her boyfriend, her companion on the street, convinced that he was duplicitous and “trying to be slick.” At the thought, her voice rose to a sharp, panicked pitch. “If he really cared about me, why didn’t he ride in the ambulance with me?” And then, as if reconsidering, she corrected herself. “When you love somebody, you push through,” she said.

Her confusion emanated toward the nurse, a calm Black man in his 40s. He sat at a computer behind a high counter, and his main problem that night was this woman who would not stay in her bed but kept circling back to his station trying to make herself understood. She had been judged by a doctor to be a danger to herself and thus in need of immediate hospitalization, so she was waiting for a bed on an upstairs floor. But the nurse had other patients to care for, too. He came out from behind the counter. “It sounds like you’re having a hard time right now,” he said to her. She responded loudly, angrily, about the boyfriend and the ambulance. “I can’t talk if you’re talking,” he said. He suggested a dose of Ativan, and over time, she grew calm but still had concerns. “Where am I going to go when I get discharged?” she asked the nurse.

It was the right question. When, in late November, Mayor Adams announced an initiative that would expand the powers of the NYPD and EMS to remove people who appeared to be mentally ill and homeless from the streets, involuntarily, to hospitals, he seemed to overlook a basic point. People who are unhoused — whether mentally ill or medically ill or intoxicated or simply in need of a safe place to sleep — already use the city’s hospitals all the time. They come voluntarily and involuntarily, on foot, by ambulance and police van, and comprise 10 to 20 percent of patients in any city ER at any moment. Some come in so often the staff greet them by name on the subway; in the ER, they are referred to, mordantly, as “frequent fliers.” You’re going to bring every homeless person to the hospital, and we’re going to fix it?

Upon hearing the mayor’s directive, frontline workers didn’t know whether to laugh or to cry. The city’s ERs — the gateways to care for any person in any mental-health or medical crisis — were already at capacity, underfunded, understaffed, and coping with a dire shortage of psychiatrists and mental-health professionals. The ER doctors who, under the Adams plan, would be charged with moving homeless patients into psychiatric treatment zeroed in on one line in the mayor’s announcement: that Governor Hochul had agreed to add 50 psych beds to the city’s inventory — a drop in the ocean when the entire state has just 5,000 psych beds total, a 20 percent decrease from 2014. Meanwhile, homelessness in New York City has soared 35 percent over the past decade, to more than 65,000 individuals. Most New Yorkers who are homeless live in shelters and don’t experience mental illness, but 30 percent of them do, with the highest concentration of the severest cases — schizophrenia, major depressive disorder, borderline personality disorder — among those who live on the subways and streets. “I’m just like, What. The. Fuck,” said one attending physician at a large city hospital’s ER. “You’re going to bring every homeless person to the hospital, and we’re going to fix it? There’s no room in the system.”

So far, only NYPD officers are being trained in the directive. But no cop wants to wrangle with a sleeping person on a platform to force him to the hospital; no ER nurse wants to do triage on more people who don’t want or need intervention; and one ER psychiatrist told me he believed it was “reckless” to funnel more people experiencing homelessness to the emergency department when research has shown that Black patients undergoing psychiatric evaluation are sedated and restrained more often than white patients.

For all the political rhetoric about “compassionate care,” the ER has a narrow, unsentimental function: to resuscitate patients who need to be resuscitated and to identify dangerous conditions. Given the hard realities of living on the street, patients who are unsheltered frequently present a full slate of intertwined maladies. If they suffer from mental illness, it often goes untreated and hand in hand with substance abuse and the chronic conditions that stem from poverty and neglect: liver disease from alcohol; cardiovascular disease from smoking crack; hepatitis or HIV from intravenous drug use; diabetes, asthma, or congestive heart failure. A patient may arrive at the ER incoherent because she is high or because she has bleeding in her gut, and the job of the ER is to diagnose, prioritize acuity, and stabilize. “We are the make-it-work doctors,” one told me. ER staff are under pressure not to dwell on what comes before or after the problem in front of them, but when they do think about the scope of this disaster — the map on which homelessness and mental illness converge like enormous storm systems — they acknowledge how little they can do. The patients hate the shelters, but there are too few alternatives. After a day in the ER, they may feel better and want to leave. And a person who is competent is free to go. So the ER doctors, with few other options, often knowingly discharge people back onto the street.

On January 15, 2022, Martial Simon, a homeless man with schizophrenia, pushed Michelle Go in front of an R train at the Times Square station, killing her instantly. It was Adams’s first month in office. Something had to be done, fast, to reassure New Yorkers that the subways were safe. Within a month, the state’s Office of Mental Health released “interpretive guidance” for “involuntary inpatient psychiatric admissions.” The usual standard for involuntary admission is “imminent danger to self or others”; now, the standard would be broadened to “an inability to meet basic living needs.” Any person who could not feed or wash themselves or was defecating in public could be brought to the hospital against their will. In an attempt to capture potentially violent people like Simon, the document essentially gave the NYPD a basis for taking people to the hospital for being homeless.

The legalistic guidance went largely ignored for nine months until Adams announced his own version, predicated on it, in November. Civil libertarians immediately took issue. “Hospital is not prison,” said Josh Goldfein, a staff attorney at the Legal Aid Society. “A person who has not been accused of a crime cannot be jailed. All the cops can do is take them to the hospital, and the hospital has to follow the same rules it always has.” In the city, every person who is hospitalized involuntarily gets a lawyer, a protection against the historic abominations of institutionalization. Beyond a standard observation period, no psychiatrist can admit a patient or force them to take medication over the patient’s objections without a judge’s consent; inside Bellevue is a courtroom that doctors, patients, lawyers, and judges can use.

Nowhere is there more appreciation for the ethical and practical problems a person like Simon presents than in the ER. People with schizophrenia, homeless or not, tend to cycle through ERs and psychiatric hospitals — admitted, stabilized, discharged, and readmitted. Most doctors believe this is not an optimal or healthy way to live, but they also believe patients have the right to live suboptimally. “We respect that people have a fundamental drive to survive, and that depression and chronic suicidality are part of the human condition, and that people have a say in the way their lives play out,” explains Omar Mirza, a psychiatrist at a New York City public hospital. (In her State of the State speech this month, Hochul announced a $1 billion plan that included opening meaningfully more psych beds. The mayor’s office, conceding that the city has “a long way to go” in providing post-discharge options, pointed to major investments in supportive housing.)

Even so, Mirza adds, “there’s this tiny sliver of patients where it’s absolutely clear that they meet the criteria for an involuntary hold. Obviously, if someone comes in and is acutely homicidal, this isn’t a place where we can respect their autonomy.” A responsible psychiatrist understands that “imminent danger to self or others” isn’t a literal standard. If a person says he is following commands coming from the television set, he doesn’t also need to say he’s homicidal or suicidal. He needs to be admitted because no one can predict what the television voices will direct him to do. One ER psychiatrist told me about a homeless patient so infested with lice that her hemoglobin was low. Her psychosis impeded her ability to tend to her basic daily needs, and she had become anemic. She was admitted too.

Quietly and among themselves, though, some ER and psych doctors wonder whether the pendulum has swung too far in the direction of patient autonomy. It’s not that they agree with the Adams directive, which they see as a blunt instrument. Of the 3,400 people living on the street on any given night, about half have severe mental illness, a rough estimate by people who work with them. Of these, the overwhelming majority are not violent or dangerous, but a small fraction can be. Between 5 and 10 percent of people with schizophrenia don’t respond to the most effective drugs, and a much larger portion don’t always take them. “It’s definitely the case that most people with schizophrenia do not commit violent crimes. It’s also true that people with schizophrenia are more likely to commit violent crimes,” one psychiatrist told me. “Either we develop more efficacious treatments for schizophrenia, which are not around the corner, or we commit to keeping those unresponsive to treatment in the hospital for their lives. Or we accept the death of Michelle Go.”

When a patient walks through the door of an ER, the triage begins. What is acute, and how acute is it? Is the top-level problem medical or psychiatric? Housing status and psych history are crucial data points. Is the patient’s schizophrenia or depression exacerbated by substances? The decision tree grows from there: Medical problems get treated by the medical team — including alcohol or drug poisoning and withdrawal — while psych problems get a psych consult. A patient who is intoxicated but stable will be shown to a bed to sleep it off; psychiatrists can accurately assess the mental state only if the person is sober. And all of this is complicated by the patients themselves, whose manifestations of mental illness are variable. A psychotic person can sometimes pull it together to avoid hospitalization, and a healthy person can malinger in order to sleep in a bed. On the night I visited, a woman came into the ER claiming suicidality to evade a man who was bothering her near the shelter where she lived. Then she insisted to the doctors that this was self-preservation and she was in her right mind. (The doctors concurred.) All she needed that night was train fare back to the shelter.

That evening, the acute medical section of the Brooklyn ER was “a disaster,” everyone said. (I was permitted to embed on the condition that I grant the hospital, staff, and patients anonymity.) Patients on gurneys lay everywhere: in the bays, alcoves, and curtained cubbies and then in ad hoc rows in front of the bays and alcoves. There were people with sepsis, stroke, infection, and a possible heart attack. There was a man wearing a long, beaded cross sitting upright in bed crying, “Please, please, please,” and a woman covered with bloody vomit yelling into her phone. A gray-faced elderly man lay on his back with his knees up under tented blankets, agitated and twitching. He had inoperable cancer, the attending physician told me. “You can see he’s actively dying,” he said before turning away to bid good night to his kids on FaceTime. “We are very good at life or death,” he added later. “We are much less good when someone needs a cup of coffee.” When a patient walks into an ER, the triage begins. What is acute? Is the top-level problem medical or psychiatric?

Beyond was the area for people with non-life-threatening illnesses, and here lay an older man. He had been living on the street for most of 27 years, he told me. He hated the shelters. “I’ve seen guys getting raped. I’ve seen guys getting killed in shelters,” he said. “No one in their right state of mind would turn down three meals a day and hot water to stay in the street” unless the shelters were worse.

The man had been to this emergency room several times in the past week. During this visit, he was lying on a gurney when the triage doctor, a cheerful, charismatic young woman, came over. Seeing her, the patient asked for pain meds (she offered Advil). And a COVID test. And he wanted her to look at his feet, which he believed might be frostbitten. This was a common request from homeless patients, the doctor told me later, to draw out the list of complaints to extend their stay. Was he interested in an alcohol treatment program, she asked?

“Absolutely,” he said.

The man told me his story: divorce, layoff, layoff, a series of visits to psych hospitals, making money by collecting bottles and cans, sleeping in an abandoned pickup truck during the recent frigid spell, which was cold, but he had a comforter. Then he said this: “Someone poisoned me with fentanyl two and a half weeks ago. It killed me so fast.” Soon he was searching in his backpack for hospital records showing proof of his death. He too had a history of major depressive disorder and substance abuse. The doctor connected him with an inpatient treatment program.

The triage doctor has many feelings about the Adams directive, first among them her strong opposition to any increased police presence in the ER. Already, cops sometimes accompany an aggressive or a psychotic patient who is under arrest to the ER in handcuffs and stand guard for days, making the staff and other patients upset. Earlier that evening, the cops had brought in one man because the shelter where he lived had deemed him too intoxicated to enter the building. The doctor thought this was ridiculous. The man was amiable, just slurring and off-balance. At check-in, he was given a yellow wristband that read FALL RISK. She reiterated a view I had heard from many others — no one’s mental health is helped by being forced into an ambulance by police.

“Do you drink every day?” the triage doctor asked the man with the wristband.

“Yeah, but I don’t drink too much,” he said. Then he mentioned that he has high blood pressure and stage-five brain cancer. He drew a line with his finger from the back of his skull forward through his hair.

Does he have mental illness? I asked her. Maybe, she said. But it was likelier that he was only intoxicated. A diagnosis would become clearer over the next several hours as he sobered up. She gave him a paper cup of water, and, walking swiftly away, she reminded me: There is no stage five.