SCENES FROM A PRACTICE Homeless Ben

AFTER THEY FOUND HIM SHIVERING AND huddled in an alley corner downtown, the Dallas police brought Ben to Parkland Memorial Hospital. Delirious and homeless, he had ended up where many 1 ike him had-the emergency room of the county’s public facility.

For the past 10 of my 30 years in practice as an internist, I have worked rotations in the ER, teaching young medical students. For six grueling weeks at a time, our tight team of medical residents and medical students works to solve the problems presented to us from the emergency room.

The morning after Ben’s arrival, the senior medical resident gave a report on him during our team’s rounds.

“The patient is about 30 years old and was unable to give a history because of delirium,” said the resident, a 25-year-old man who was in his second year of training. He recited the facts in a brisk monotone. “He is apparently homeless and was brought to the emergency room with a fever of 104 degrees. The physical examination was remarkable for the fever and a skin rash consisting of erythematous lesions of about I centimeter in diameter, some of which were blistered and others crusted. The lesions involved predominantly the trunk, face, and proximal extremities. The palms and soles were spared. This morning his temperature is only slightly elevated, and he is more responsive.”

It was the usual succinct and pithy summary I had come to expect from this resident, but it was delivered with a tone of disdain. I was getting used to that from him as well. He was even-tempered in a sad sense. Parkland no longer held any surprises for him: he had seen all manner of people, plights, and disease. You could catch him from time to time daydreaming, perhaps about the private practice opportunities and the relief from the frustrations and fatigue of the county hospital.

“OK, let’s go see him,” I said.

When we walked into the room, Ben was in a fetal position on the bed, his back to the door. He rolled over when he heard us. He had bright red hair and a full red beard, both disheveled and dirty. The room was filled with a musty odor- Ben’s odor. His skin showed the sores with enough clarity to make the diagnosis obvious. Ben had severe chicken pox.

“Hello, Ben. My name is Dr. Burnside.”

“Ell-uh-whoa.”

’’I beg your pardon.”

“ELL-UH-WHOA!”

Ben had a speech impediment, something no one had noticed when he had been brought in. His face grimaced with the effort of speech; sound started in his throat and was then forced out through his nose.

We gathered in a horseshoe around the foot of his bed-the senior resident on one side, I on the other, and the other students in between. Ben was facing me and responding to my questions. It took time, but soon I could understand the awkward words of his speech. The resident wasn’t listening; he stood with his arms folded across his chest and his eyes focused on a spot where the wall met the ceiling. Suddenly Ben snapped his head toward the resident and shouted at him.

“Don’t stand like that. It’s too authoritative!”

That was a show-stopper. No one knew quite what had happened. Before anyone could respond, Ben said, “That’s the way the police behave!”

This was the voice of experience, and when we heard it, we all realized at once that our assumptions about Ben-that he wasn’t very bright and had little insight to offer-were wrong. During his stay, Ben continually surprised us with his observations and perceptions of the world.

Homelessness has been in the news a great deal. Some simple thinkers believe that all homeless are downtrodden, mistreated, and oppressed, and that given adequate resources, all would choose to live differently. Others contend that no one need be homeless, and that if the homeless are without shelter, it is a choice they’ve made for themselves. I decided to ask Ben about it.

“Ben, how long have you been on your own?”

“Long time,” he replied. “Lett home when was about 14.”

“How long have you been in Dallas?”

“About a year. was in Mexico for a couple of years before coming here.”

“How did you fall on such hard times?1’ I asked.

“What hard times? I’m all right. People leave me alone and I get along OK. Jesus keeps me out of trouble.”

“How did you get along in Mexico? Do you speak Spanish?”

“Can’t speak Spanish-can’t speak English, as you’ve noticed,” he laughed. “It was easy, though. I just drew pictures and held them up and showed them what I needed. Sometimes they would give me money for my pictures. I could get a large poster board for about 50 cents and sometimes get good money for it when I tin-ished.”

“Ben, if you had your choice, where would you live?” I asked.

“Probably Florida. I have some friends who were headed that way and I would like to find them.”

“You mean i:hey live there?”

“No, they’re just there,” he said. “They move around like me.”

Time passed slowly for Ben. He was confined to his room because his chicken pox was contagious. We put a few dollars in his bedside jar so he could rent a TV, but he didn’t watch it much. He wasn’t very sick by the third day. but we also couldn’t discharge him to the street.

1 told my son about Ben one night and he suggested we get him some drawing materials. We got a thick pack of heavy bond, a six-pack of colored Marks-a-Lot pens, and a brown manila folder with the string ties that lawyers and draftsmen like to use.

Ben was delighted, screwing up his face in a big grimace, making his speech even more difficult to understand. He immediately proceeded to make his drawing. It was the same as others he ’d done before- the only drawing he ever did. Soon, everyone on the uni: had one of Ben’s pictures. It was a large flower of yellow petals and green leaves, over which he wrote “Thank you Jesus for Loving Me-Amen.” This was the coin of Ben’s realm. It moved him wherever he wanted to go and got him food and money on the way. It was also what Ben most wanted people to “hear” from him.

As Ben approached the dry stage of h is skin lesions, we asked Social Service to see if we could find him a shelter for his final convalescence. The social worker did come, but the result wasn’t what we’d expected: She left a very terse note recommending psychiatric intervention. According to the note, Ben had been rude and in a “delusional state.”

“Ben, what happened between you and the social worker?” I asked.

“She wanted me to go to the Salvation Army Shelter,” he said.

“What’s wrong with that?”

“They talk dirty over there, that’s what. It’s like I said earlier Doctor, people just need to leave me alone. I don’t have to go somewhere I don’t like. She really made me mad. If 1 don’t do what she wants, I’m a bad guy.’’

Ben finally got to leave the hospital. I asked him where he was headed and he showed me his bedside jar.

“Florida,” he said. “I’ve got Florida in the jar. Sixty-eight dollars here will buy me a bus ticket. Course, I also have my paper and pens.”

For Ben, that was plenty.