by Robert Lanz, LCSW
Graduate students in the field of social work generally choose a specific area of interest to specialize in. The students select their specialty and then apply for an internship that reflects that specialty. Those students with a predisposing personality in which they are comfortable (or at least think they are) working with the sick and dying often choose to work in hospitals or medical clinics. Life is markedly more acute in hospitals than it is in most social work agencies and nowhere is that more obvious than in the ER. Because of that acuity, the students spend the first months of their hospital rotation ‘upstairs’ where the acuity moves at a slower pace and there is plenty of support around to help take up the slack during the learning process.
In the Emergency Room, especially at night, the only support staff for the students is the social worker on duty. The good part about that is they get a lot of one-on-one and have the opportunity to see an experienced social worker deal with the worst events at the fastest pace. Of course, that can be intimidating. Most of the students survive but very few of them want to specialize in working in the worst and fastest zone. Those that do, for whatever reason, are predisposed to welcoming a challenge. Some of them may start out thinking they won’t like this work, then learn to be good at it and decide to pursue it. I like to think that for some of the students, this is partly my fault.
Most students share the same fears when they start out. Most fear that they won’t know what to say to a patient or family when they approach them at a moment of crisis, having no pre-existing relationship with them, kind of like what they refer to in the world of retail sales as ‘cold calling.’ The ‘catcher,’ (the person in crisis) doesn’t know much, if anything, about what it is the ‘pitcher’ (the social worker) actually does in the hospital. The ‘student pitcher’ only knows that something is terribly wrong and that he or she needs to use growing social work skills to massage the situation for the best possible outcome under the circumstances. These circumstances might include time limitations, the lack of previous connection, constant interruptions by staff including doctors, nurses, phlebotomists, etc. The noise level is often high and there is no privacy most of the time. Of course, the interns are intimidated because they aren’t sure what to say. They think I have some magic pitch that always works and they’d love to borrow it to help overcome their natural discomfort.
More important, I counsel them, that learning a canned pitch is to learn the signs and symptoms of a faint –not just for the benefit of the patient or family but for their own benefit as well. The ER’s overwhelming smells alone are enough to induce a faint, a gag or even a vomit reflex –hardly the presentation of confidence that will successfully guide the intervention. As to the ‘magic pitch,’ of course I don’t possess one because the pitch isn’t formed until you see how the patient reacts when you enter the room. Then the feedback-loop begins and the social work stuff can enter into the process. If the patient sits up, makes eye contact and says hello it will be a lot easier to connect than if the patient is facing the wall, has his head covered up with a pillow and doesn’t acknowledge your arrival. As I always preach: start where the client is. A client covered by a bed sheet will be more difficult to engage than one who sits up and greats you openly.
If you have been reading my stories you will have seen that there are many ways to make that connection, and all of your life experiences will probably be more useful than anything you’ve learned in a social work textbook.
The social work textbook doesn’t say — when you enter a patient’s room and she is covered in a sheet — ‘just do ABC.’ Nope. ABC is yours to figure out. What would you get you to come out from under the sheet if you were the patient? To answer that question you might go on line and try to find an old copy of Thomas Gordon’s book, PET: Parent Effectiveness Training. When I was doing social work interventions in juvenile hall (where there were teenage equivalents of a ‘sheet over the head’) his advice was incredibly helpful. I’m also sure that none of the learned textbooks included the various forms of threats and intimidations available as adjuncts to the basic social work evaluations and interventions. I think the books are remiss, but I guess that’s why the schools send students into internships where they can actually watch practicing clinicians ply their craft instead of reading books and listening to lectures by tenured professors.
Here’s just one simple example of intimidation/threat I have used several times over the years. A patient comes to the ER with a suicide attempt/gesture, usually an O.D. or wrist-cutting. These signs of impulsivity usually emanate from desperation rather than a major depressive disorder. Those with a true major depressive disorder are more likely to really hurt themselves and a threat from me is not helpful. The issue here, aside from the patient’s psychiatric and medical needs, is the degree to which the patient is willing to cooperate with the evaluation. If I can’t get all the information I need, I can’t make a good evaluation. Sometimes that requires threatening behavior on my part.
The social worker should always read the patient’s complete medical chart and get any history of prior episodes of impulsive or self-destructive behavior. Then, when you go into the patient’s room you have the information you will need to figure out the best plan for the patient. The impulsive patient is often young, often angry and lacking insight. You should always allow the patient a chance to give a history of the events that brought him or her to the ER. While listening to this history, you are able to show empathy and understanding and perhaps get some idea of the person’s current insight and impulsivity.
Or not. If active listening and empathy don’t allow for the gathering of sufficient information and the patient looks like he/she will remain uncooperative, then it is time for the threat. It goes like this: “Look. I need you to cooperate with me. I’m concerned with your safety but you aren’t being open about your situation. My job is to decide whether you need to stay in the hospital or not. Right now, because you aren’t giving me the information I need to make that decision effectively, I’m going to admit you so that you don’t hurt yourself. What I’m going to do is go see a couple of other patients and then come back and see you. Your job, if you think you’re safe to go home, is to try and talk me out of my decision to admit you. Any questions?”
Usually, I don’t actually have to leave and come back after that threat, the patient responds to the threat immediately. I consider that a good sign.
Let me add this: in thirty years, I did thousands of suicide evaluations and not one patient who I sent home ever killed himself or herself. I have sent patients home who eventually killed themselves but it was always after being in treatment or being evaluated by a subsequent mental-health professional. I’ve admitted patients who spent two weeks in the psychiatric part of the hospital then killed themselves after they were released. I’d say I made the right decision four to five thousand times, and part of that is because I was able to utilize threats and intimidation when such interventions were useful.
Let’s get back to the grad students and creativity. The second problem they often have is confronting violence and threats of it. I once had a female student who was a black belt in karate, and she was more adept at confronting violent behavior than most. The male students, and there were few of them, were more used to violence and were less uncomfortable confronting it. With all of my students, I required a thorough reading of the chart and a conversation with the patient’s nurse before going in to start the evaluation process. If there was any fear at all, the student was advised to take a male nurse or one of the male techs in the room as a back up.
I always advised them on safety issues: don’t close the door; don’t let the patient get between you and the door; if you sense violence, never present a large target to the patient; standing sideways reduces the strike zone by fifty percent — your vital organs are not openly exposed and neither are your eyes. If the patient is scaring people, then I advised the student to confront the patient about that directly by making a statement like: “I think you might have scared your nurse. Sometimes people who do that are scared themselves.” See what happens. Sometimes you can even ask the patient if they would be more comfortable in restraints. Many would.
In my career I was only struck one time. I went to interview an intoxicated, blind, eighty-four-year-old woman who had been acting-up at home. She was on the gurney facing away from me when the interview started. She had been calm since her arrival by ambulance, so my guard was down. She spoke softly, so I leaned over her shoulder and asked her if she would repeat what she had said and she literally blindsided me with an over the shoulder right-hook and got me right in the nose. It wasn’t a hard shot but a nose-shot doesn’t have to be hard.
Hope for the best. Plan for the worst.
Finally, students are often concerned about dealing with patients who have been disfigured by the violence of falls, traffic accidents, gunshots, pedestrians hit by trains, etc., and how they will respond to them. First, refer back to the beginning of this story. Learn how to recognize a faint. And believe that you will develop defenses against those olfactory, auditory and visual intrusions into your senses. A good social work preceptor should find a way to help that process along.
The trauma room had two beds. A female patient in bed one had been in a significant traffic accident. She was in an older car without airbags and there was speculation that she hadn’t used her seatbelt, since her body lacked the common pattern of bruising that goes hip to hip and shoulder to hip across the chest. In any case, her forehead struck the steering wheel and she suffered a typical avulsion injury, peeling the softer scalp back from the harder forehead, leaving the top of the skull exposed for all to see. The new social work intern had observed this from across the room while standing in the doorway. It isn’t just important for the students to recognize a faint coming on, it is equally important for the preceptor to keep an eye on the students in case they haven’t learned the fainting recognition skill yet. I did that just in time as she went from leaning on the door jamb to free-falling, and I grabbed her before she hit the ground, moving her to a chair nearby and putting her head lower than her heart. It was a simple faint and she came-to immediately. An hour later, when the patient had been stabilized and her avulsion stapled back to the top of her head (yes, stapled) and all the blood was washed off, she looked much better.
I went in and switched the beds, telling the trauma nurse what I had done. I then asked the student to go into the trauma room and see the woman in bed two. Bed one was now empty and I was sure the student would be relieved to note that. I told her bed two had been in a minor accident and might want to contact her family.
Unaware of my ruse, the student went in, spent a few minutes and came to tell me the patient was fine and that someone had already contacted her family. She added that the patient seemed to have good coping skills and didn’t seem to need any interventions.
“Did she look familiar to you?” I asked.
“The last time you saw her you fainted. That was the lady in bed one.”
“Yes. It might help your faint reflex if you recognize that how they look when they get here is not how they will look when they leave. Your body lied to you and responded to a very temporary situation like it was permanent.”
Lesson learned. Class adjourned.