Panic Attack

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by Robert Lanz, LCSW

Panic attacks are one of the most common presentations to the ER and sometimes the most vexing. I suggest that every social worker in that setting make a point to have a really good pitch because it will be thrown often.  Being able to use your relationship with the docs to get the patient medicated when appropriate and get some aftercare meds, too, is as essential as your referral to the appropriate follow-ups, whether that be yoga, biofeedback, insight counseling or whatever else. Your “pitch” should convince the patient that you are highly competent in this diagnosis and that your observations should be followed ASAP for the requisite relief.  Of course, the panic attacks may be part of a whole host of other problems including depression, generalized anxiety disorder, recent stress, unresolved grief, etc.  Those issues are too time-consuming to address  fully in the ER, but your ability to finally address them successfully leads to your air of competency on the subject, and that leads to a more likely follow-up by the patient.

A lot of patients come to the ER suffering from panic attacks. Some of them even come in saying they are having a panic attack because they have had them before. Some come in and think they are having a panic attack because they know someone or read something about panic attacks, realized they were under a lot of stress and that stress was often the cause of a panic attack. Then there are those “others” who come in believing that they are having a heart attack, pulmonary embolism or some other type of total meltdown. Thanks to the ER docs recognizing the commonness of the presentation, there is general agreement that there is no need for anyone to suffer the debilitating effects of a panic attack. Patients are often given immediate relief with a shot of Ativan or some other medicine like it.

The panic attack patients — and there are many of the — usually get referred to the social worker because the SW is the mental health professional in the ER and because panic attacks can be very, very insidious. It is important that they get treated quickly in the out-patient world, just as it is important to receive quick treatment in the ER. Otherwise, the literature seems to indicate there is a good chance the attacks will happen again. (I guess ‘bad chance’ may be a more appropriate choice of words: there’s nothing good about a panic attack except that it may be a somatic epiphany of some sort.)

Anyway, my job was to help the patients identify any recent stress that may have been a contributing factor to their panic attack. Here, I do have to add that a lot of people are clueless when they are under stress and sometimes questioning has to get pretty specific. I might ask the patients if they have been under any undue-stress lately and follow that up by asking what they usually do to de-stress themselves. Then we can discuss some appropriate follow-ups like psychotherapy, stress management, yoga, tai chi, biofeedback — you get the picture. Well, I hope you do. Many patients don’t. That’s when I have to get specific.

panic_attack

“So have you been under any stress recently?”

“No, not really.”

“How’s it going at work?”

“Oh, I lost my job a couple of weeks ago.”

“How long did you work there?”

“About 26 years or so.”

“And how’s it been going at home?”

“Well, since I started drinking again, not too good.”

“You mean your wife’s angry with you?”

“No, she left.”

“She left?”

“Yeah, she went to stay at my mother’s.”

“Well, maybe that will be temporary.”

“I don’t know. My mom’s been feeling bad lately. My dad died about two months ago and it’s been affecting her.”

“Anything else? You didn’t get arrested or anything?”

“Just a DUI”.

“Sometimes it’s hard to say exactly what causes people to have panic attacks but it seems like you may be experiencing a lot of changes lately. Change can be stressful”.

Conversations like this are what caused me to develop calluses on my tongue. There are so many great lines I could give back to someone under these circumstances, but since I am the mental health professional it would be in bad taste to say what I am thinking. I just stay with the standard pitch, which I won’t bore you with now.

So let’s get back to the woman in room 7. She’s pretty average. Has a decent job. Looks a little younger than her age. Kind of cute. Very relaxed by the time I got in to see her. She had been so anxious when she came in that the charge nurse moved her out of the group room she was in and put her in a private one. A private room and a shot of Ativan make it so much easier for me to interview the patient.

This should be pretty routine, I thought. Yeah I know: it’s foolish to think anything will be routine in the ER. The only thing routine in the ER is that nothing is routine. ‘No routine’ is the routine. It’s a Zen thing.

Tonight, two non-routine things happened almost immediately. The patient’s mother comes in at a critical juncture in the interview. The patient is about to tell me she broke up with her boyfriend of seven years because he wants to have kids and she has some disorder that her doctor said would make it impossible for her to get pregnant. At that very moment, the nurse walks in and tells the patient she has a positive pregnancy test. Of course, the woman speaks-up and says there must be some mistake. “I can’t get pregnant and why would the doctor order a pregnancy test if I’m only having an anxiety attack,” she wonders out loud. The nurse beats it out of the room and comes back 20 seconds later. We are still in recovery mode so not much has been said.

The nurse says to the patient, “Did you give me some pee?”

And the patient says she did. And the nurse explains that the doctor had ordered the test on the woman who had been moved out of the private room and into the hall and it was the current patient’s urine that was tested — and the pregnancy test did in fact, come back positive. She offered to do another one to be sure but the patient declined. Probably too stunned or too stoned to think that one through.

The patient’s mother was ecstatic. Her daughter had finally gotten pregnant. The patient was confused — how could she get pregnant? Then there was the issue of the breakup over no pregnancy that led to the stress that caused the panic attack that brought the patient to the ER. Ativan is a pretty safe drug, so we wouldn’t get sued for giving it to a pregnant woman. It was one of those honest mistakes that happen in a busy ER. Sorry folks, but that is reality.

So here we are, the patient very “relaxed” but about to start talking about the breakup and Mom starts getting all pumped up because she thinks her daughter will finally get married to the boyfriend who she really likes, and I’m sort of an afterthought by now.
But all these issues? They aren’t ER issues. ER issues are about why you are here right now.

We fixed that with the shot and reality reared its ugly head again with the pee mistake that lead to the positive pregnancy test in a woman who thought she could never get pregnant and to the true delight of the mother. But that doesn’t mean it rises to the level of an ER issue.

“It would be a safe guess to say that the panic attack you had today was related to stress in your life.” Then the mother broke in, saying “But now she’s pregnant and everything will be OK”.

Maybe it will. I don’t know. I went on ahead with my basic pitch about the nature and treatment of panic attacks, referred her to a local counseling center where they had clinical social workers and marriage counselors. I also thought she would benefit from biofeedback and gave her the number to a psychologist who does that across the street from the hospital. And then I left.

I don’t know if the patient ever told her mother what had really happened. I wondered if she would tell her boyfriend now that she had broken up with him. I don’t imagine she would have gotten an abortion because she was very close to her mother and wouldn’t want her to know. There were so many things I was curious about but few I really needed to know. I had done my job. I had made my pitch

And I was out of there. Next…

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The Goofball Brothers

Goofball brothers

by Robert Lanz, LCSW

I was hoping to think of a kinder euphemism for a pair of brothers from New York but I wasn’t able to do it. I’m sure some readers will take offense and attach some clinical label to their behavior that will somehow provide cover for their deplorable acting out.  Wherever they went, everything they did was self-destructive. And expensive. Expensive jail time. Expensive “upstairs” in the hospital time. Very expensive ER time. They were unrelenting goofballs and in the end, both dead. No surprise to anyone.

If they could have gotten their money back for all the tattoos they paid for maybe they would have stayed indoors and lived a little longer. More likely they would have just gotten more stoned on whatever drug was available to them when they woke up. Indoors to them was jail and the hospital. Why spend their own money on food and rent when they could just spend yours? A good investment to you would probably be something safe like a muni bond that paid four percent. A good investment to them would be to get together enough money to buy a big chunk of black tar heroin — wholesale, so to speak. Not that they would have dealt any of it; they would just have had more to shoot-up at relatively cheaper prices.

But they never had that much money, certainly not enough to stay loaded on the tar. No problem. When there was no tar, there was Vicodin. No Vicodin, then there was Xanax or some other benzos. No benzos, no problem.  Any anti-psychotic would work, or even alcohol in a pinch. It wasn’t so much where they were going to end up, anywhere was better than where they were when they woke up: sober. Sobriety was the worst place for them. Sobriety in jail. Sobriety in the hospital. Sobriety in the dumpster. Location meant nothing compared to sobriety.

They were too arrogant or too stupid or too stoned to realize, that sometimes the world in its perfection, needs to collect a debt for bad behavior. Someone owed a life or two, and it was time to pay. These pseudo-biker, over-inked tough guys had moved to the head of that line with bad choices and bad behavior. They were due to make a payment and everybody knew it.

Somebody smelled the decomposing body of the older one in the dumpster behind a convenience store on the east end of town. The needle in his arm was a not-so-subtle clue to the cause of death. The younger brother took it like he took his whiskey: hard. Drink enough-and he already had a near lifetime of practice-and your liver develops the scarring of cirrhosis which diminishes its filtering ability. Toxins build up in the body. The portal vein backs up and causes esophageal varices, which leak blood down the throat and into the stomach. Blood is such a strong irritant that outside of its vessels, it causes severe discomfort and irritations that leave the stomach in pain, and a frequent reason for alcoholics to come to the ER to get pain meds.

“I’ve knowingly drunk myself into alcoholic gastritis and now I want you to give me some synthetic heroin so I don’t have to feel my pain.”

The bleeding into the stomach causes the stool to look like, well, the tar heroin that killed the older brother. I believe that this may qualify as irony. After the liver stops working effectively, the pancreas gets involved. Much worse than alcoholic gastritis, I was told by several patients with pancreatitis.

When I was in the cancer hospital I met a couple of guys who had pancreatic cancer. Both had been heavy drinkers. Both were on high doses of opiates, addiction to drugs being the least of their problems. Oh yeah: both of them looked really sick. Context is everything. When you look really sick in the cancer hospital, it is ominous. Arms like spiders. A belly like a pregnant man. Sunken dying eyes. Skin the color of a banana or worse, like someone who tried to self-tan in a vat of carotene.

That’s how the younger brother ended up in our hospital. The resident caring for him in his death throes late at night called me up to his room. Just prior to my arrival he had mustered his last bit of strength to get out of bed, pull out his IV’s and blow chalky stool laced with blood all over the floor before the nurse could respond to his alarms. They were still cleaning him up, in restraints now, when I arrived.

“He’s fading fast, Bob. Not much left for us to do. Try to make him comfortable with some morphine. Does he have any family or anyone to contact?”

“No family I ever knew about. Just a brother who died in a dumpster a few months ago. No friends, either. Nobody liked him. But the morphine part, he’d like that.”

After about half a million bucks of jail and hospital time, that’s how he died. Slightly better than in a dumpster. Only slightly. Thanks to opiates, I guess they both died in peace.

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The Student

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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.

Like this:

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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.

“No. Why?”

“The last time you saw her you fainted. That was the lady in bed one.”

“No.”

“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.

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Hypnotherapy

Hypnosis

by Robert Lanz, LCSW

In the early eighties I studied hypnotherapy with a psychologist named Sheila Rossi. She and her ex-husband, also a psychologist, had studied under a famous hypno-therapist named Milton Erickson. Dr. Erickson’s specialty was hypnotizing people who either didn’t want to be hypnotized or thought they couldn’t be induced into a hypnotic state. Hey, that’s the perfect kind of hypnotherapy for the Emergency Room.

Of course, being the upfront guy that I am, I told the doctors I wanted to be able to use hypnosis as a tool in the ER. Perhaps if I had been a slightly more aware social worker I’d have realized it would have been better to bring up such an arcane technique only after I had a few more years under my belt and a more solid reputation. Of course, a physician with no training at all in hypnotherapy might be allowed to induce hypnosis in a patient but a licensed clinical social worker with eighty hours of training would not. For me, that was just another rule set to overcome.

On the very the night I was told that it wouldn’t be appropriate for the social worker to perform hypnosis in the ER, I realized that a good clinician could substitute the term “deep relaxation” for “hypnotic induction” and no one would be the wiser. I was an experienced enough social worker to be allowed to do that.

Dr. Erickson, as noted, was famous for pulling people out of the audience during his lectures and hypnotizing them at the same time he was explaining why he wouldn’t be able to do it. In no time, he had the un-hypnotizable person on stage enjoying a deep, relaxed hypnotic state. No jumping around and acting like a chicken or any of that Las Vegas hypnotist-show stuff. A hypnotherapist should only induce a person for positive reasons, to help the individual in some way.

One of the keys to these inductions is to pick the right subject, for example, a person who is already making eye contact, which is a form of interpersonal communication and a key to establishing trust. From there, it is a matter of understanding what that person wants or needs. Through observation and feedback, the person will provide guidance to the therapist and the induction can take place.

Now, that is a method I knew could be very useful in the ER-as long as I didn’t call it hypnosis. And that’s just what I did with varying degrees of success over the years. In many ways, it was like trying to shoot a music video in a nursing home. No privacy. Constant noise. Bright lights. HIPPA rules. But the video you get is a delight to the residents so you do the best you can under the circumstances. I was surprised that it worked at all but over time, hypnosis became a valuable addition to my tool kit.

What I couldn’t have predicted, until I had to use them under dangerous circumstances, was that Dr. Erickson’s techniques could not only help bring a difficult situation under control, but would save my butt in the process. Oh yeah. A couple of staff members saw the whole thing and asked me later where I had learned that trick. They, too, sensed the danger and were amazed and relieved that things went the way they did. I was, too. It had been a long-shot but it was the only shot I had:

A young man had come to the trauma center after being shot several times. He didn’t survive. His friends — mostly rough gang guys — and his family were all in the quiet room when I told them about the man’s death. That would be the moment the quiet room ceased to be quiet. Cursing and loud wailing took over. Walls were punched. Chairs were thrown. As usual, I remained stoic. It took about ten long minutes of my stoicism for everyone to calm down enough to finally view the body. At least that’s what I thought.

As soon as we opened the door to start walking down the back hallway, the victim’s mother went down hard. Not hard as in falling on her her face or banging her head vigorously, hers was more of a swooning fall. Now remember: I am an Emergency Medical Technician as well as a social worker, and at that moment Mom needed an EMT a lot more than she needed an LCSW.

“Does she have any medical problems?” I asked her husband.

“She takes some medicine for her heart.”

Great. Something for her heart. Now she’s on the floor, not a doc or nurse in sight. From where I was, kneeling down next to the unconscious mom, I could see Danny, the ER tech. At that very moment that ER tech, who had worked with me for years was staring right into my eyes. We were about to have an Ericsonian moment.

“Danny. Move that baby out of room nine. Put her and her parents in the hall. We need to get this woman into that bed, and do an EKG.” Done in an instant, despite the fact that I had gone far beyond the scope of my ER social work job description.

My victory was short lived however. The victim’s younger sister, a big girl of about seventeen, went to ground just outside her mother’s room and had a full meltdown and flailing tantrum on the floor. The tantrum brought the rest of the troops  –about fifteen in all — out of the quiet room. They took up a position where they could not only observe the full tantrum’s effect, but also hear the full amplified effect of the victim’s mother, still unconscious, hooked up to the beeping EKG machine. I was right in the middle of that mix and couldn’t have been more vulnerable to the impending attack of the hostile crowd reacting to emotional pain with physical violence instead of with tears like many of us might have done.

Behind me, Danny was finishing up with the EKG. In front of me, the hostile crowd was seething with negative energy, and between the seething crowd and me was the large teenage girl screaming and jerking on the floor.

I looked at the crowd. I looked at the girl. I looked over my shoulder back at Danny. Like any good EMT, I did a primary survey of my environment and realized I was in trouble and could easily end up a patient in my own trauma center, a victim of mob violence.

Apparently the ER was so busy that no one heard the commotion. I was alone. Well, I thought I was alone. Then it occurred to me that Dr. Rossi and Dr. Erickson were with me. I glanced at the crowd again and realized that one of the gang guys was looking me square in the eyes. He was desperate for me to take control.

“You.” I pointed at him, “Take this girl back to the quiet room. She needs some water.”

Bam. Like magic — or more like Dr. Erickson coming into the audience to do an induction — the young man did just as he was told. The crowd parted and the young man took the victim’s sister back to the quiet room and everything calmed down.

The EKG was fine, according to Danny, and I reassured him that if there was any trouble for me making him do the EKG that I would take the heat. He knew that already, of course. I went and told the charge nurse what had happened and got a chart started on the fainting mother who took some kind of heart medicine.

“Good work, Bob,” she said. “We were really busy up here and didn’t even know you were in trouble.”

Maybe it was coincidence, I don’t know. I didn’t ask. A couple of months after that incident, one of the surgical residents came up to me after a difficult trauma code.

“Bob. I’m really stressed out. Can’t sleep and I’m having trouble concentrating. I heard you can hypnotize people.”

Yes, I could. It just took me twenty years to admit it.

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Sick For A Year

Bob lanz

by Robert Lanz, LCSW

I thought about my surfing buddy and neighbor in Mexico, Woody. “All I want to do is smoke pot, play the blues and surf.” And that’s what he did until he got cancer. Then he went home and died. We buried his ashes near his favorite surf spot with his headstone reading “Gone Surfing”.  And my other surf buddy also in Mexico told me he thought he got cancer when he was in Vietnam in the Marines. He went home to Oregon and died too. He has Charlie’s Trail, a mountain bike trek , named after him.

And I thought about my friend Rita, the pediatric social worker upstairs who nurtured me through the early years of the horrors of the child abuse team. She came into the ER one night as a patient and died a few months later from liver cancer.

My writing partner Mindy, one of the first female paramedics in our town,  a true inspiration, had such a long battle with cancer I thought she would win.  She didn’t. And my favorite nurse Margo who flirted with me for twenty years as we aged together on the night shift. She frequently left our ER to go to a better place where she could more easily ride her horse, but she always came back to us. Well, not always. She really is in a better place now I guess.

When I was racing cars in the eighties my friend and staff physician Andy was there with me and other racers used to kid us that we were the only race team that had our own ER doc. Pancreatic cancer took him so fast we didn’t have much of chance to give him the proper send off.

And I miss Carole, one of my own night shift social workers,  gone at age 37 to breast cancer and Beverly the night shift nurse who did the same. And after saving The Last Dance For Me, my favorite charge nurse died too.

My neighbor Sal died of throat cancer shortly after I was diagnosed with it. Then another old friend and neighbor from high school came out of remission and died just about the time I finally started to feel confident that I wouldn’t.

And when it looked for sure like I would be OK I was called by an upstairs social worker from my own hospital to visit one of my oldest friends, surfing and skiing together most of our lives. He was dying from head and neck cancer and we only had enough time for a few more stories, bench surfing I guess and then he was gone too.

Two friends and a neighbor in the year I was sick myself, gone.  A year of being sick. It was a very sick year…Bob

Like any smart guy at that time I got my PSA checked annually. Finally one year, the results were slightly elevated but not by much, and the body of scientific literature on the subject was nothing compared to what it is today. In some ways I’m glad it wasn’t.

The mysteries of an elevated PSA vexed a lot of guys in may age group (I was sixty-two at the time), including my internist of fifteen years and who wasn’t sure what to do. Same with my previous internist, an ex-ER doctor and long time friend. He had borderline PSA’s himself and he didn’t know what to do either. When a couple of guys you’ve trusted your life with for more than twenty years don’t know what to do, it’s beyond disheartening and this became a real fear factor situation. The idea that something might have been cooking inside of me and no one knew what to do except “watch and wait” created some severe anxiety. When you work in the ER and see people go from well to ill in the blink of an eye, denial is not an option. Watching and waiting didn’t seem like much of an option either.

My older brother settled the watch and wait matter a week later when he called me to drop the bomb that he had been diagnosed with prostate cancer. I was on the phone the next morning and at my internist’s office that afternoon. The cancer diagnosis in a first degree relative was the tipping point and I was off to the urologists for a biopsy. I won’t bore you with the details of that old story except to say that it was a grind. Surgery. Catheters. Diapers, Viagra and all the other things that guys often avoid at the risk of dying rather then living with these possible side effects of prostate treatment. Not me. I was only sixty-two and with longevity in my family genes, I figured I had another thirty years in the bag.

A year later, everything was working fine and I experienced only a brief scare when my surgical biopsy showed that some cancer cells had escaped my prostate gland and were found in the soft tissue right next to it. Luckily, that turned out to be a big nothing and my ensuing annual PSA tests were zeros. After five years everyone said “You’re cancer free”, and I was. Free from prostate cancer at least.

Lance Armstrong is used as an example for many things, some good and some bad but mostly bad on the point of pathology as we now know with certainty. In the documentary film, “The Armstrong Lie”, he talks about the progression of his testicular cancer. A testicle the size of a lemon. Abdominal pain. Coughing up blood. Headaches and double vision. But through the pathology of denial he didn’t seek medical care and the cancer metastasized all the way north to his head and he had to have a tumor removed from his brain. A year of denial almost killed him.

After having prostate cancer, I found his book about his cancer experience compelling.

So one morning, three years after having retired from the ER, I lathered up for a shave. When I pulled my facial skin tight to even out the wrinkles and provide a smoother surface for the razor, I felt a large lump just below my jaw. Without a second thought I set the razor down and felt the other side of my neck. It was normal. No swelling there. Bad news in a way. Nothing is a hundred percent in medicine, but an enlarged neck lymph node most commonly has a match on the other side and indicates a localized infection.

I hadn’t had any dental work recently. I was not sneezing or wheezing and I didn’t have a sore throat. Less than ten seconds after feeling the lump I knew I had cancer. Unlike Lance, there wasn’t any denial in my bag of pathological tricks.

I was on the phone to my internist immediately and in his office that afternoon. He set me up with an ENT doc for a consult the next day. That doc thought I was over-reacting and advised the “watch and wait” approach. Easy for him to say. I thought he was too young to know much about things like that and he sort of dismissed my take on it. After all, he was two years old when I started working in the ER and I knew my own body. He thought it was impossible to tell without some tests so he stuck a needle into my lymph node and set me up for a PET scan. The scan was positive but the needle biopsy wasn’t. Two weeks later I was at the outpatient surgery center and had a throat biopsy. Positive for high grade squamous cell dysplasia, the last stop before carcinoma on the arc from totally normal to the “Big C”. Should I fire that youngster and go to a cancer-only hospital? Positive.

At the cancer-only hospital I was set up with an interventional radiologist. He did another lymph node biopsy, this time the right way, guided by an ultra sound machine. It was positive. Two weeks later I was in the chief throat surgeon’s office. By this time I had had so many positive biopsies that everyone pretty much knew I had squamous cell carcinoma, and the surgeon was almost a hundred percent sure it was the HPV 16 type.

“I like to do my own workups,” she said. “So we’ll have to start again.”

That was a meaningful statement for me. A couple of times in the ER, I had depended on some other person’s opinion when I was too busy to do my own workup and it ended badly. I put my hand on her arm and gave it a little squeeze.

“You got the gig.”

The nurse, the nurse practioner and the surgical resident apparently weren’t used to seeing endearing physical contact on the first date and acted like they didn’t see the move. In spite of my mounting trepidation, I felt that this was going to be an interesting journey.

Believing that the second deep throat biopsy would be a simple four-hour deal like the previous one at the outpatient surgery center, I asked one of my nurse friends to drop me off. He left his number, thinking he’d be back soon. I thought so, too.

I woke up groggy in unfamiliar territory. It sure as hell didn’t look like a recovery room to me. My surgeon was standing directly under a clock that said 11:00 exactly. Hmmm. That’s strange I thought. The surgery started at ten and there was my surgeon, right on time, saying through my fog, “We did good. I think we got it all.” She left pretty quickly. Five minutes later I noticed it was still eleven o’clock. I was really stoned and unable to figure out what had happened. When I saw the ICU sign outside my door I thought most likely I had gone into cardiac arrest during the procedure and had to be resuscitated.

“Hey, what day is it anyway and I think I’m hallucinating,” I yelled out to no one in particular. Most nurses wore scrubs and in thirty years I’d never seen one topless-not at work anyway, and yet there they were, coming in and out of my room topless. It was very confusing for several hours. At least I think it was several hours. The clock was still on eleven.

I hit the buzzer and called the nurse into my room. She had all her clothes on so I figured it was safe to talk to her.

“Look” I said “I spent thirty years in health care so I want to approach this as delicately as possible. If it wouldn’t get you in trouble with my surgeon can you tell me exactly what happened?” Just to be sure I was returning to my right mind I told her about the topless nurses.

“Propofol” she responded. “You were in the ICU on a Propofol drip for twenty two hours. You know, that Michael Jackson thing.”

Yeah, I thought. That Propofol thing that killed him. Luckily, I’d gotten off the bus at the topless nurse stop, but I did have a better appreciation for why Mr. Jackson liked it so much. He probably didn’t hallucinate topless nurses, but you get the picture.

“During your biopsy, the doc saw a band of sick cells at the base of your tongue and decided since she was already down there she might as well laser that zone so you could get a jump on the chemo and radiation coming your way. There was already a breathing tube and a fiber optic scope down there so to make room they had to grab your tongue with a big pair of forceps and pull it out, way out, to make room. That traumatized your tongue and they were afraid of swelling so they had you on the ventilator for almost twenty four hours in ICU. you had a Propofol drip the whole time and it might effect your memory.”

And my vision too, I was thinking. “What time is it, anyway?”

“The clock says eleven.”

“It always says eleven.”

“Your memory is coming back.”

She wrote something in her nursing notes and left.

WTF. Now I’m the catcher, not the pitcher and I’m being tested after being on a Propofol drip for twenty-four hours. Maybe I shouldn’t have mentioned the topless nurses. Most likely, I failed that part of the memory quiz, too.

The next time my nurse came back it probably seemed like I was flirting with her because, well, I’m a man and she’s a woman and a beautiful one according to the notes I was now taking, too. We talked about working in hospitals and other professional matters. I told her a couple of funny ER anecdotes and she laughed. Maybe she was flirting back with me. Or maybe it was the Propofol.

Anyway, at change of shift the new nurse came in and introduced herself. She was sweet. She kept her clothes on and I could remember her name. Which is a lot better than with the previous nurse who, it seemed, I felt closer to. Or maybe it was that twenty-four hour drip. I consulted my notes but couldn’t tell.

Gradually, over the next twenty hours, I rebooted my brain. Told a few more funny stories, took a couple of calls from my wife and friends who were pretty worried. The nurse friend who had dropped me off for the biopsy was freaking out waiting for a call to come and pick me up. He thought I might have coded, too.

When you’ve had your tongue seriously tweaked, even after twenty four hours in ICU, there is still some danger, so I couldn’t lay flat to sleep. Sitting up at a forty-five degree angle brought back memories of when I had epiglotitis. I couldn’t sleep then, either. Maybe my time on Propofol would have to do it for me sleep-wise for a few days.

I guess I passed the rest of the memory tests because they let me go home the next day. Fifty hours later than I had originally planned. I was able to remember my second and third shift nurses names but not the name of the pretty one, and that isn’t like me. Must have been the drugs. Maybe it was the drugs that had me in denial, too, taking what my surgeon said literally when she told me she thought they had gotten it all. Not like me either.

I was disappointed the following week when I went for my post surgical follow-up and confirmation of the throat biopsy. They hadn’t hit any cancer spots in my throat, just more of that high grade squamous cell dysplasia like the ENT kid had found. No matter. The positive finding in my lymph node was all that really mattered. I was given a follow-up to meet the radiologist and oncologist who would be doing my radiation and chemotherapy. First the cut. Then the burn and the poison. Adios, denial.

Luckily for me, my first day of chemotherapy-an all day affair-found me in the care of an old friend from the ER. The emergency room, especially the night shift, is so brutal, it is common for nurses, as they age out, to end up in places like cancer hospitals where the cruelties of life are still very present but at least the pace is manageable. When she saw my name on the list she bumped the scheduled nurse. That’s what any ER nurse would have done and it meant a lot to me to start that part of the journey with a friend. I had the normal amount of trepidation about my treatments and starting with a friendly face made it slightly more tolerable.

At the end of six hours of chemo (and in case you didn’t know it, the violent vomiting doesn’t start for a few days) it was down to radiation where unfortunately, I didn’t know anyone.

The first day and every subsequent day, for that matter, are a nightmare for throat cancer patients if they are at all claustrophobic. That’s me. I found that out the hard way fifteen years ago after a back injury and a trip down the MRI tube. It took twenty milligrams of Valium to get me back in the machine to finish the procedure.

It was almost as bad down there in radiology where they make a half-body mold that covers your face and head and extends all the way down to your waist. It is an open mesh mold, made up of one-inch squares so you can see OK and breath OK if you don’t have a panic attack like I had with the MRI. However, the mold is hard and it has metal snaps all along the edges. So does the stiff board you lay on when you slide into the tomography/CT machine. Because all radiation beams are so precise in their rotations around your head, it is important that you don’t move. Unless you suddenly lose a lot of weight, movement is not a problem. You might as well be nailed to a cross. Six minutes in the machine then six minutes out while the machine is calibrated with a computer and then back in the machine for six minutes or so of burn time. About twenty minutes bolted firmly to a board, looking up into a machine that is working to save your life, but it doesn’t feel like that when it’s happening. Lots of amygdala time. Torture.

They do let you bring your own music, and the radiology techs could not have been sweeter, even if they had been techs that I had known from the ER. It takes a week or so before the effects of the radiation start to kick in, right about the same time that the chemo is at full force. It’s downhill from there, even months after the treatment ends.

Some of my social work friends asked me what they should tell patients about that whole process. Simple answer. On the day you get diagnosed, start on some anti-depressant medication and eat as much of everything as you can for as long as you can because you’re sure to lose weight and you’re sure to experience the fatigue/depression effect to the point that death might feel like a welcome break in the routine. For a few days I was so fatigued and depressed that if someone would have told me “we can keep you alive as long as you want but this is how you will feel,” I’d head for the famous bridge not too far from my house and go for that big air finale. The sickness of radiation and chemo is ten times worse than seasickness and altitude sickness-both of which I’ve had. They are characterized by their unrelenting and horrible symptoms.

Cut, burn, poison, torture and at the end, death. Nothing dignified about that. Nothing heroic about that. Like a lot of patients I would try to act brave to soften the blow on my loved ones so they could better deal with the pain of my impending death. But not for long. If there was just death at the end, this wouldn’t be about them. It would be about me. Spare the torture, take me straight to death. It might be harder on everyone else but it would be a lot easier on me. At least that’s how I felt for a few days. There’s a lesson here. No one enters into grief willingly. I could help you deal with that issue by dying sooner.

A couple of weeks into the chemo and radiation, some of the bodily functions you take for granted slowly slip away. Your saliva dries up and your taste buds stop working. The radiation burns on the inside of your mouth get so bad that even custard hurts. Sometimes your mucous gets so thick (mucositis) that it fills your throat to the point of setting off your gag reflex and that causes choking that sets off your vomit reflexes. Despite all the anti-nausea medicines, you are ready to puke any time and the mucositis just hastens the process. One night it got so bad I puked myself into the dry heaves and dehydration and I had to go back to the cancer hospital, get some IV fluids and stronger anti-nausea medicine and spend the night. I threw up so hard I hurt my back and thought I might end up back in that MRI machine again for another round of torture and fear. PTSD here I come. That was just one of the nights I had fleeting regrets about my treatment, thinking I should have tried to just squeak out a year of wellness before the cancer actually began to hurt me. So far, the cancer hadn’t been a problem, but the treatments sure as hell were.

At the cancer hospital, I met other patients who had been in treatment for years. Years! Despite my thirty years of experience in health care, it was almost unfathomable to me, since I was feeling totally wimped out by the experience myself after only a few months of treatment. I should have listened to my own advice. Pass the Paxil and bring me a green chile burrito and a cold brew. Oops. Too late for that one. Can’t taste beer anymore. Can’t taste burritos either. I’m stuck with high protein green slime drinks and they hurt my radiation-burned mouth and throat. Even water tastes bad.

I discovered that losing your taste buds doesn’t mean you stop tasting things, but that you stop experiencing good tastes. Bad tastes remain and that is how almost everything tasted: bad. Road apples without benefit of having hit the road-straight from the horses ass.

Before I got sick I was a pretty robust guy for my age. I’d ride my bike around the lake where I lived almost every day. I’d go boogie boarding down at the pier during the summer and I often drove my car up to the mountains nearby to hike around. I’d even paddle out at the beach near my house in Mexico from time to time, despite the embarrassment caused by aging and not being able to catch the waves I wanted to. Three weeks into my treatment I could no longer do any of those things. It was all I could do to drive the half-hour out to the hospital to get treated every day. After that it was just couch lock, too exhausted to even nap. Just me and TV and smoothies-boring compared to the life I so recently lived. I lost so much weight, my doctors threatened to put a feeding tube into my stomach. I was borderline anemic and could barely make the hundred-yard walk back to my car after radiation.

Then it got worse. I became so fragile I had to sit down to take a shower. My blood pressure would swing almost a hundred points in a day. I was getting so dehydrated, I had to have a home IV nurse come out and hang a liter of fluids five days a week. My veins were so bad, sometimes it took ten tries to find a good one for the IV. Geez, I used to send the home health nurse out to take care of sick people and now I’m sick people and she’s at my house.

I kept forgetting about my near anemic blood counts and experienced about forty near faints just getting up from the couch, having to do a controlled roll to the floor and once not making it, getting clocked on the head by my front door. Another time, I was so exhausted and apparently looked so bad that my wife thought I had died. Her crying woke me from my stupor.

No one totally ever tells you how bad the fatigue can get. It was nothing like the fatigue my body felt after a good day of surfing or skiing which left my body tired but my mind clear and stimulated. This fatigue was the kind my suicidal patients told me about in the ER. Unrelenting negativity. Soul busting loss of caring about what would happen next. A home invasion and murder would have been a relief. I developed an acute understanding of why people jump from high places. Brutal.

I also gained a better understanding of my anorexic patients. Initially the radiation and chemo only took away my sense of taste but I retained my sense memory of food, often craving some deliciously presented meal I’d see in a TV commercial. Then gradually that was replaced with a non-sense memory of what I used to have a sense memory of. Soon, the very thought of food was repugnant to me. After losing fifty pounds, it still didn’t matter and if not for the berating from my wife and her forced smoothies, I would probably have starved to death. That didn’t matter much to me, either. Life itself didn’t matter much at that point.

I had made a full transition from a professional mental health provider to a person who no longer cared about anything. The dregs. Well, not entirely. I still feared the feeding tube and my wife, I guess.

Something clicked about that time and I had a social work/mental health epiphany: Just follow my own advice. When I told my social work colleagues what to tell their patients about the treatment experience, to start on antidepressants and pig out, I was right. Hello Paxil my old friend.

On and on it went-smoothies for breakfast, drive to the hospital, get strapped to the sliding board in the tomography room, try to avoid an anxiety attack. Drive home, have a smoothie and watch TV-well not actually watch TV, that took too much energy, more like exist in the same room as the TV. I didn’t read. Too hard to focus. Couldn’t remember anything anyway-chemo brain. Too much energy required to play my guitar. I stared at the floor for hours, then choked down another smoothie. I became acutely aware of how much I missed something as common as saliva.

Somehow, my treatment team at the hospital thought I was doing well. My radiologist scoped me and thought my throat looked good. My oncologist thought my labs looked good. I thought, felt and looked like crap.

One day I decided to actually look at the lab results myself. My blood counts were terrible. My red blood cells could barely carry enough oxygen to keep me out of the anemia zone. No wonder I had no energy. That’s when I had another epiphany. As I learned when I was studying screenwriting, context is everything. “Good” is a relative term. My throat didn’t really look “good”. My labs weren’t really “good”. My labs and throat were only good in the context of belonging to a guy who had been bombarded with chemotherapy and radiation.

“So when do I get my taste buds back?” I asked my radiologist.

“Hard to say. Takes time. Be patient. We’ll know more in three months.”

The last time I heard that line it was me saying it to a patient who kept returning to the ER after getting diagnosed with Parkinson’s seeking reassurance from me that he didn’t seem to be getting from his doctor. Now I wondered if maybe I could have spent a little more time with him. Maybe I owed him an apology since I knew exactly how he felt. We now shared a fearful level of desperation.

I have a very hard time being a patient. I have a hard time not being able to do the things I used to do physically. I have a hard time doing without some of the simple things I enjoy like eating a juicy burrito and riding my bike. It’s been a year since I finished my treatment regime and I’m still sort of sick and weak. There are about twenty things that taste OK, so I’ve had the exact same breakfast every day for eight months. Dinners have only the most minor variations and I still have to drink one of those high calorie smoothies every day. I’ve gained about fifteen pounds back and don’t look so sick any more. My hair is finally growing normally, but somehow it got curly. Half of my beard, the part on my neck where radiation was strongest, never did grow back. I’m OK with that. And I can finally taste beer.

I still have to go back to the hospital for labs every three months and then there is the three-month and the six-month scoping along with frequent lymph node groping and I’ve had my first one-year-out CT scan. Everyone seems to think the cancer is gone but no one will be definitive about it. I think it’s gone but the effects of the treatment still linger. It probably doesn’t help that I’m almost seventy years old and have had couch lock for eight months or that I’m so out of shape I don’t even bother to take my boogie board when I go to the pier and read. As we used to say in the sixties, this is a bum trip.

“Be patient, Bob. We’ll know more in six months,” all the doctors say.

Yeah, and in another six months you’ll tell me you’ll know for sure in a year. And finally after five years of this, if all the scoping and labs and scans are normal, then I’ll be cancer free. Easy for you guys to say. None of you are even forty yet. I might not have five more years and if I do, that would give me enough time to get another type of cancer and we’d have to kiss and make up and start all over. Hey, that’s PTSD talking.

Looking back with a clearer mind, I wonder if maybe I should have spent some time with the social worker at the cancer center. She would have known exactly what to say to prevent this PTSD feeling I carry around with me. She would have known exactly what to do with all my fear and anxiety. After all, she was one of my graduate students during her internship at my hospital and had a darn good teacher.

I’m not a guy who gives up easily, but I was doing some serious wavering after the second round of chemo. If an airplane had crashed into my house it would have been all right with me. It would have put an end to what seemed like endless hopelessness. That was then.

Now I’m not so hopeless. I’m taking walks. I’m taking drives in my new truck. I’ve even cleaned up my bike but haven’t ridden it yet. When I do, maybe I’ll ride over to the ER and see if anyone there wants to go to lunch.

Dividing line

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The Docs Aren’t Always Right

Medial snake

by Robert Lanz, LCSW

Social workers don’t have a lot of say in medical matters except when we occasionally point out the obvious, which may not have been obvious to everyone else, including the county resident pulling a shift in the ER. Including the ER attending physician who was supposed to be supervising the county resident. Including the pediatric resident who went along with the consensus, believing that, after 20 years of practice, the ER attending had to be right. In this case, the obvious was obvious only to me, and I was only working on a strong feeling I had, independent of medical knowledge.

A baby was brought in with a rash on his bottom, and the resident made the initial diagnosis of herpes. Herpes can only be contracted by intimate contact with someone with active herpes lesions, which could include contact occurring during the birthing process. It’s known that some docs even use an expectant mother’s herpes lesions as a reason to perform a C-Section. I don’t know much about that.

What I do know about, after traveling south for most of my life, is the culture of rural Mexico and Central America. The folks who live in these regions are called campesinos and many of them are fairly typical of the desert border-crossers trying to get to the U.S. in order to have a better life. In the 80’s, when this event occurred, my experience had been that most of the campesionos were shy people, easily embarrassed. And it was a shy, easily embarrassed couple who were waiting to see me because the ER resident didn’t speak much Spanish. He was suspicious about what he thought was herpes and considered it a reportable finding.

This made me somewhat uncomfortable because people who looked like this couple had welcomed me into their homes many times. I knew I was going to be causing them significant discomfort with the sexual nature of the questions I would have to ask regarding the little pus-sacks on the infants bottom. But my personal feelings didn’t matter, so I went ahead and did what had to be done. I looked over the baby’s body for any other marks and found nothing but a healthy baby who reached for his mother when not in her arms. I asked the parents if either of them had herpes, but they didn’t understand, so I had to explain. Lucky for me, they thought I was a doctor, too. Very shy people. Easily embarrassed.

They both denied having herpes. They both implied they had never been intimate with anyone else but each other. Given my cultural and language disadvantages I had no choice but to believe what they told me. The resident wanted to admit the baby because if the initial outbreak of herpes virus is vigorously treated, it may be the only occurrence. He also wanted to isolate the parents from the child during the investigation about the herpes exposure. To be honest, it didn’t look like any herpes I had seen on other kids, but I wasn’t the doc. Fortunately, I was the guy who wanted to cover all bases when feeling uncertain about a diagnosis.

“Call over to the main ER and have Dr. J. come over,” I said to one of the nurses. “I want the attending to see this kid before we start some investigation.”

That didn’t work. Dr J. said, “The kid’s got herpes, Bob. Admit him and call Children’s Services.”

It was late and the Children’s Services people said the same thing. Admit the patient and they would come over in the morning. I had a feeling they were all wrong but what could I do? The pediatric resident came down and I told her that it didn’t look like herpes to me and that the family really didn’t seem like people that would neglect their kid.

“Looks suspicious to me, Bob,” she said. “I’ll admit him. We’ll culture those lesions.”

So I left a note for the pediatric social worker. Then I left a voice message expressing how I really felt. Can’t be writing my feelings in the chart, an official document. But I had worked with the peds social worker on many cases and I knew she believed that I had sound judgment. Still, at that point it was Docs three, and SWs zero.

The next day I was busy from the moment I arrived and didn’t think about the kid upstairs, at least not until I ran into the pediatric attending in the cafeteria.

“I saw your notes on that kid you guys admitted last night. You sounded a little tentative about the situation.”

Here we go, I thought. Docs four, SWs still zero.

She said, “I got the feeling you didn’t think those lesions were herpes.”

“Well, they didn’t look the same as the herpes we usually see.”

“That’s because they weren’t.”

I was all over the resident for missing that and getting social services involved. I don’t know how they got impetigo confused with herpes, but they did.

She suggested, “Maybe you ought to say something to your docs down there.” Oh yeah, I thought. That’ll work.

I said to her, “I have a better idea. You’re the pediatrics doc. Why don’t you go on over there and tell them and keep me out of it?”

I guess she did, because I never heard another word about it.

Dividing line

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