Alfred Handley leaned back in his wheelchair alongside a major Phoenix freeway as a street medicine team helped him get rehydrated with an intravenous saline solution dripping from a bag hanging on a pole.
Cars whooshed by under the blazing 96° morning sun as the 59-year-old homeless man with a nearly toothless smile got the help he needed through a new program run by the nonprofit Circle the City.
"It's a lot better than going to the hospital," Handley said of the team that provides healthcare to homeless people. He's been treated poorly at traditional clinics and hospitals, he said, more than 6 years after being struck by a car while he sat on a wall, leaving him in a wheelchair.
Circle the City introduced its IV rehydration program as a way to protect homeless people from life-threatening heat illness as temperatures regularly hit in America's hottest metro. Homeless people accounted for nearly half of the last year in Maricopa County, which encompasses metro Phoenix.
Liz Frye, MD, MPH, vice chair of the that provides training to hundreds of healthcare teams worldwide, said she didn't know of groups other than Circle the City administering IVs on the street.
"But if that's what needs to happen to keep somebody from dying, I'm all about it," Frye said.
As , health providers from San Diego to New York are being challenged to .
Even the , featured in last year's book, Rough Sleepers, now sees patients with mild heat exhaustion in the summer after decades of treating people with frostbite and hypothermia during the winter, said Dave Munson, MD, the street team's medical director.
"It's certainly something to worry about," said Munson, noting that temperatures in Boston hit 100° with 70% humidity during June's heat wave. Homeless people, he said, are vulnerable to very hot and very cold weather not only because they live outside, but they often can't regulate body temperature due to medication for mental illness or high blood pressure, or because of street substance use.
The Phoenix team searches for patients in homeless encampments in dry riverbeds, sweltering alleys, and along the canals that bring water to the Phoenix area. About 15% are dehydrated enough for a saline drip.
"We go out every day and find them," said nurse practitioner Perla Puebla. "We do their wound care, medication refills for diabetes, antibiotics, high blood pressure."
Puebla's street team ran across Handley and 36-year-old Phoenix native Phillip Enriquez near an overpass in an area frequented by homeless people because it's near a facility offering free meals. Across the road was an encampment of tents and lean-tos along a chain-link fence.
Enriquez sat on a patch of dirt as Puebla started a drip for him. She also gave him a prescription for antibiotics and a referral to a dentist for his dental infection.
Living outside in Arizona's broiling sun is hard, especially for people who may be mentally ill or use sedating drugs like fentanyl that make them less aware of surroundings. Stimulants like methamphetamine contribute to dehydration, which can be fatal.
Temperatures this year have reached 115° (45°C) in metro Phoenix, where six heat-related deaths through June 22. Another 111 are under investigation.
"The number of patients with heat illnesses is increasing every year," said Aneesh Narang, MD, assistant medical director of emergency medicine at Banner Medical Center-Phoenix, which treats many homeless people with heat stroke.
Narang's staff works frequently with Circle the City, whose core mission is providing respite care, with 100 beds for homeless people not well enough to return to the streets after a hospital stay.
requires a dramatic response, said physician assistant Lindsay Fox, who cares for homeless people in Albuquerque, New Mexico, through the University of New Mexico's School of Medicine.
Three times weekly, Fox treats infections, cleans wounds, and manages chronic conditions in consultation with hospital colleagues. She said the prospect of more heat illness worries her.
Highs in Albuquerque can hit the 90s and don't fall enough for people living outside to cool off overnight, she said.
"If you're in an urban area that's primarily concrete, you're retaining heat," she said. "We're seeing heat exposure that very quickly could go to heat stroke."
Serious heat stroke is far more common in metro Phoenix, where Circle the City is now among scores of health programs for the homeless in cities like New York, San Diego, and Spokane, Washington.
Circle the City, founded in 2012 by Sister Adele O'Sullivan, MD, a member of the Sisters of St. Joseph Carondelet, now has 260 employees, including 15 doctors, 13 physician assistants, and 11 nurse practitioners. It annually sees 9,000 patients.
Grants, donations, and other gifts account for about 20% of the funding. Most of the rest comes from insurance payments for services provided through Medicaid and Medicare.
Circle the City works with medical staff in seven Phoenix hospitals to help homeless patients get after-care when they no longer need hospitalization. It also staffs two outpatient clinics for follow-up.
"This partnership allows us to offer the best outcomes for our patients," said Craig Orsini, social work manager at St. Joseph's Hospital and Medical Center in Phoenix.
Often that's a few weeks in respite care or, for less acute needs, a stay in one of a handful of medical beds at the downtown shelter for things like dressing changes for wounds. Someone who needs months to heal might go to a skilled nursing facility.
While patients recover, Circle the City works to find longer-term transitional shelter such as those for people 55 and older, or in permanent housing. About 77% of respite patients are sent somewhere other than the street or an emergency shelter.
"We try to find the best fit for people," said Wendy Adams, Circle the City's community outreach supervisor.
Circle the City medical staff distributes tens of thousands of water bottles each summer and tries to educate people about hot weather dangers, said Matt Essary, DO, who works at one of five mobile clinics that stop outside soup kitchens and other services for homeless people.
Essary said Circle the City is also considering a blood analysis tool to detect electrolyte imbalances caused by dehydration.
"You can see right away how dehydrated they have become because it's so hard to draw their blood," he said. Other possible symptoms include headache, extreme thirst, dizziness, and dry mouth.
"We also see a lot of people with surface burns," Essary said of the wounds common in broiling Phoenix, where a medical emergency or intoxication can cause someone to fall on a sizzling sidewalk.
Rachel Belgrade waited outside Circle the City's retrofitted truck with her black-and-white puppy, Bo, for Essary to write a prescription for the blood pressure medicine she lost when a man stole her bicycle. She accepted two bottles of water to cool off as the morning heat rose.
"They make all of this easier," said Belgrade, a Native American from the Gila River tribe. "They don't give you a hard time."