A Clinical Approach to Preventing Death on the Streets
Every day in cities around the globe, men and women experiencing homelessness lie sick or injured on sidewalks, often inches away from potentially lifesaving help. Yet passersby, even health care professionals, routinely walk past as if they are worlds apart. In the US, adults living on the street have a death rate almost 10 times that of the general population.1 Many people experiencing homelessness literally die on sidewalks.2
When fellow human beings are in need, clinicians typically jump to respond. Most (69%) physicians report they would definitely help a restaurant diner clutching his chest.3 Most (54%) would definitely respond to an airline passenger in need. Only 2%, however, report definite willingness to help a disheveled person lying on the sidewalk. While potential Good Samaritans may be inhibited by stigma or fear of catching a disease, there is another reason that may help explain the low likelihood of clinicians intervening for a person on the street: the lack of a clinical framework to guide action.
People experiencing homelessness are among the most clinically and socioeconomically disadvantaged in the world, disproportionately affected by medical, psychiatric, and substance use disorders.4 Based on our experience as practitioners caring for patients through the Boston Health Care for the Homeless Program, this Viewpoint offers clinicians a framework—one that is missing from general clinical training—for assessing a person in need on the street (Figure). Notably, this framework applies to situations in which a clinician is concerned that a person may be clinically unwell (eg, lying in an unusual position, appearing in distress, or showing signs of trauma). Given the lack of rigorous evidence in street medicine to date, this framework can serve as a general approach that accommodates clinical judgment until more evidence emerges.
Approach to Clinical Assessment
The first step when a clinician is walking toward a person in need on the street is to assess the situation’s safety. If approaching the person could lead to physical or mental harm, the clinician should not feel compelled to engage, and could call local authorities if concerned about the person. Many municipalities offer alternatives to calling 911 for emergency assistance. Clinicians should familiarize themselves with their city’s resources, such as 311 which in some cities partners with outreach teams. Beginning in July 2022, there will be another option. Created by recent Federal legislation, 988 will be a mental health emergency hotline and crisis response system that does not rely on law enforcement.5
If approaching the person appears to be safe, the clinician should visually assess the person’s level of alertness. If the person is clearly awake and appears stable, simply engaging in a brief nonclinical verbal exchange may suffice. People on the street often cherish a simple “hello” or other acknowledgment of their presence.
A person who is awake but appears in clinical distress warrants an emergency medical assessment. The clinician should introduce oneself and, ideally, get at or below eye level with the person to help build trust, given that people experiencing homelessness may distrust medical services. The next step is to ask simply what is bothering the person and, if a response is not articulated, to assess high-risk symptoms (eg, chest pain, dyspnea, vomiting, or inability to walk). If the person needs acute stabilization, emergency medical services (EMS) should be called. If less acute care is needed, the person should be encouraged to seek help from their health care practitioner, or if not connected to such care, an urgent care clinic.
Appears Not Alert
If the person is not alert, weather dictates the next step. On extreme weather days (eg, extreme heat, cold, or rain), local resources or EMS should be called immediately given how quickly clinical status can change under these conditions. Across the country, people on the street have died from hypothermia and heat stroke,1 preventable with a call from a passerby. The clinician should then proceed with additional assessment as follows.
In nonextreme weather, a key step is for the clinician to assess the person’s breathing motions and sounds. If the person has a normal respiratory rate and appears stable, the person is likely sleeping, making it reasonable for the clinician to continue walking.
If the person is in respiratory distress, has a respiratory rate of fewer than 10 breaths per minute, or the respiratory rate is difficult to ascertain, the clinician should try to waken the person. This is most safely done through calling out by voice. If that does not work, the next step is to tap the person’s feet, which maintains a respectful and trauma-informed distance. If the person wakens, high-risk symptoms should be assessed as mentioned. If the person in respiratory distress does not waken after vigorous attempts, EMS should be called.
If the person with a low respiratory rate or no signs of breathing does not waken, a potential opioid overdose should be suspected. The clinician should check the person’s pulse and call EMS. If a pulse is detectable, rescue breathing and naloxone should be administered per basic life support protocol.6,7 If no pulse is detectable, cardiopulmonary resuscitation and naloxone should be administered immediately.6,7 Naloxone can be obtained with or without a prescription from pharmacies, and clinicians not carrying it should call out to ask if anyone nearby has it on hand, as naloxone is sometimes distributed to people experiencing homelessness. The community that forms on the street can be a rich source of helpful information. More than 90% of naloxone recipients survive an overdose that day and more than 80% are alive 1 year later.8
The Clinical Approach in Context
Living on the streets can be a dangerous and lonely experience, even as thousands of people pass by daily. This proposed clinical approach is part of a larger comprehensive strategy needed to improve health outcomes for people living on the street, including better systems of outreach and nontraditional models of care with integrated behavioral health and case management, as well as partnerships among government, legal, and housing sectors. For the time being, however, empowering clinicians with this approach may help to address a substantial clinical and public health need.
Although there is no legal obligation to intervene when walking by a person in need on the street, clinicians arguably have a professional responsibility to help—consistent with major medical society codes which recommend that physicians provide emergency care when needed.9 All 50 US states have enacted legislation to protect health care professionals who act as Good Samaritans, except in instances of gross negligence or willful misconduct.3 If our duty as clinicians is to care for those in need, then never again should a person die alone on a sidewalk without an attempt by a skilled passerby to prevent another avoidable death.Back to topArticle Information
Corresponding Author: Katherine A. Koh, MD, MSc, Department of Psychiatry, Massachusetts General Hospital, 15 Parkman St, WAC 8, Boston, MA 02114 (firstname.lastname@example.org).
Published Online: May 28, 2021. doi:10.1001/jamainternmed.2021.2402
Conflicts of Interest Disclosures: None reported.