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.

Dividing line

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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.

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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.

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No Mas

tired

by Robert J. Lanz, LCSW

There is a scene, masterfully shot, by Steven Spielberg at the beginning of his award winning movie, Saving Private Ryan, that sets the tone for the movie’s theme. An army car winds its way up a lonely country road to a n equally lonely farm house. The woman there sees the car and knows bad news is coming. There is a quick cut to the next scene, a large room full of women seated behind mechanical typewriters, clacking away. It’s obvious they are the ones that write the letters, the death notifications that go anonymously to the families who have lost a loved one in the war. Families like the one headed by the broken hearted woman.

One mother has lost several sons and someone in charge of the typists realizes she only has one son remaining, Private Ryan. He is deep in the war zone and the story line is that a special group of otherwise un-special soldiers are assigned to look for and find Private Ryan and get him home safe. No one person, mother or otherwise should have to endure such suffering.

Sometimes we feel like those guys, fighting with everything we have to stop bad things from happening, if only for a brief amount of time. A respite so we can regroup our energies. So we can reconstitute our defenses and believe again that all is not lost.

Tonight, just tonight there will be no SIDS babies or drive by shooting victims or old people run down in crosswalks. No fires that decimate families and no one’s mother will have a heart attack. We won’t have to tell a parent about their kid’s brain tumor. Drunks will get sober and no one will jump off the bridge behind the hospital and no one will hit a deer with their mountain bike.

We’ll all sit around bored but we won’t be happy. We’ll just be. Be there waiting for someone to come and save us, take us home to safety. No more carnage, an end to the war.

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THE LORD WORKS IN STRANGE WAYS!

strange ways

by Robert J. Lanz, LCSW

I just made that title up to get your attention.  For those of us who, like cops and paramedics, voluntarily participate in the randomness of violence, it is hard to maintain any kind of religious belief.  It is especially hard if you belong to a religion or sect or cult if it has a central tenet that some force or person or entity somewhere actually has some control over anything.

I have seen about as much evidence of divine intervention in the emergency room as a group of AIDS sufferers in a refugee camp in Africa on the day some idiot rebels blew up the medicine truck. That would be right before the rebels went ahead and raped the refugee women and children in a drug induced party.

Innocent bystanders, even do gooder innocent bystanders, get shot by gangbangers, run over by drunks, have babies with brain cancer or in some other way get totally fucked over in a manner they absolutely did not deserve.

Some people think that is a test of faith. Pretty cruel test I’d say.  Especially since there are so many fools that have walked away from gunshot wounds, and car crashes and falls from high places and those types of things that frequently kill mothers of small children.  They also kill fathers who go to work every day even when they feel sick so they can provide for their now fatherless children.  After a few years of these happenstances, any normal person would have to ask himself, What’s The Fucking Deal Here?

This is a job with existential crisis built into it. Anything can happen to anyone any time.  Of course, the more one puts himself into jeopardy the more the odds increase that he will take a hit. So wear your seat belt, always assume the other guy is armed, don’t get on the ladder after your fiftieth birthday and never shoot pool and drink beer in the same room. That’s about it.

Looking back on all the tragedy over the years I find that I can’t, with any eloquence, top my all time favorite bumper sticker: SHIT HAPPENS.

I always knew that. I should have invented that bumper sticker. The only difference between him and I was that he actually said it and I only thought it.

Well, there could be another difference.  He’s probably rich with a house at the beach. Me? I’m still here trying to make the tragedies in life work out a little better if I can, trying to bring some order to a disorderly world. Kind of a religious experience I guess.  The Lord works in strange ways…and I do too.

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Redemption

nature-wallpapers-beautiful-sunrise-wallpaper-31169

by Robert Lanz, LCSW

Old guys shouldn’t take call. It took me a long time to learn that and that just shows a certain level of lameness on my part. Working on the night shift is hard enough on your sleep rhythms and coming back at 3 a.m. after finally dozing off doesn’t help any. The experts say you should get eight solid hours of sleep each night. Yeah sure! They say you should go to bed at the same time every night. Uh huh! Spend some time relaxing before trying to go to sleep. That’s a good idea. You shouldn’t do anything but sleep and have sex in your bed. Sure thing. After a night shift in the ER sex is the last thing on my mind. And I guarantee, if for some twisted reason it did get on my mind and I woke my wife up to tell her about it I’d get so damaged I couldn’t even have sex with myself.

But this isn’t a story about sex or me or even sleep. It’s a story about redemption, among other things. I’ll start by saying that it is easy to forget your patients after you have finished with them. I won’t say there aren’t some you would remember. They are called frequent flyers and most are difficult patients and therefore difficult to forget. An average patient would go more like this.

I’m on call, it’s an hour before sun up and I am actually sleeping soundly and then the beeper goes off in the living room. The beeper is in the living room because since the first day I carried it the screeching sound wakes me so horrifically that by the time I get to it and turn it off I already have an adrenaline headache. Hardly the way to drive back to the hospital and deal with some trauma patient’s family.

With the beeper in the living room it takes a little time for me to hear it because I spent too much time listening to loud rock and roll in my youth and my hearing isn’t so good. My wife is a light sleeper with keen hearing and a not so gentle elbow wakes me to the point that I finally hear the beeper too. Nudged into the insanity of a guy my age sleeping next to a perfectly good woman I get out of bed and think who would be so crazy as to do what I am doing, heading to the hospital to enter into an emotionally painful event of some kind.

Anyway, all this is going to make a point soon so bear with me. I get to the hospital and find an attractive woman about thirty-five waiting for me. She is already at the hospital because the Highway Patrol has already called her and told her that her mother has rolled her car on the freeway and doesn’t look good. No one ever said why she was driving alone at that time of day and I guess it doesn’t matter. To ask the question is to imply there might be a right or wrong answer and there is enough wrong already. We talk a little and I go to the trauma room to see what is happening.

The patient is intubated, a large tube into her trachea to help her breath. Seldom a good sign. I notice the cardiac monitor doesn’t look good either and when I make eye contact with one of the trauma residents he comes over to bring me up to speed. He thinks she most likely had a heart attack or pulmonary embolism and then crashed. Her injuries aren’t too bad and don’t account for her deteriorating vital signs. No one seems to think she will live.

When I return to the quiet room where the daughter is, I keep good eye contact and she is perceptive enough to know that, despite her hopes, the news isn’t good. I explain what we are doing and tell her that her mom is not stable and her condition is grave. The daughter cries a little but starts to already accept the news she knows is coming.

“She just got back from Australia yesterday. She wanted to drive up to Santa Barbara from San Diego to see my sister. Probably wanted to get an early start.”

Bingo. Old lady. Long flight. Blood clot. Pulmonary embolism.

This is information that might be helpful to the trauma team who is working on a patient that probably needs a cardiologist or a regular ER doc rather than a trauma surgeon. When I get to the room I see the patient has flat lined and hear the all too familiar, “Let’s call it. Time out, 04:27.

I tell the resident about the trip from Australia and he just nods.

“Want me to talk to the family?”

“If you want to. Or I can do it.”

Protocol is flexible at this time of day. I get to go home and go back to sleep until my body wakes me. He has to go back to the resident’s quarters and get up in two hours and start rounds.

“Could you do this one for me Bob?”

“Sure.”

Part of the resident’s training is to learn how to give bad news and I’m one of the guys who teaches the class. I’m also the guy who prefers to do it myself because most docs just aren’t very good at it. People say that surgeons are particularly inept at it. I wouldn’t argue that point-but I wouldn’t make it either.

When I go back to the quiet room the daughter knows what’s coming so my job isn’t so hard. As I’ve said before, you never know what a person’s reaction will be but I had the feeling that she wouldn’t attack me with a chair or throw up on my shirt or blame us or any of those other less than functional reactions. She cried quietly and then told a few stories about her mom. Pretty normal grieving. I asked if she wanted to contact anyone but she said she didn’t have anyone. I felt sorry for that for a couple of reasons. First, it was sad to think at the moment of the death of your mother you would have to bear the burden of the death alone. Second because she was bearing the burden of the death alone I couldn’t hand her off to someone else and go home. Much as I wanted sleep, it was more important to help her get focused enough to get home safely, however long that took. It was about an hour and I got stuck in morning traffic and did what the sleep experts say not to do. Don’t wake up and turn the light on as that tells your body it is daytime and it will want to stay awake.

Well it was daytime and the sun was up and I was very awake. Awake and sad. I gave up a lot that night and I just wanted to be home in bed. I slid in next to my wife’s warm body, fired up one of my neurobiology learning CD’s and laid my head over my pillow speaker. I have no idea what the end of that boring CD sounds like. I have never finished it despite trying for a year.

The next day when I got to work I took report from the daytime social worker and was up to speed. She had taken care of all but one of the patients, a woman in room 8 who was having a stress reaction.

I grabbed the chart and walked into the room and thought the patient looked familiar. I looked at the name on the chart and didn’t recognize it. I could see she recognized me so I had the good sense to let her start speaking first.

“Oh Bob. You’re still here.”

“Not still. I went home and got some sleep. How abut you?”

“Not so good.”

I went through the grief drill and got her hooked up with some counseling and some meds so she could get some sleep. Hard to believe that after spending that time with her just twelve hours previously I didn’t remember who she was.

Everybody has their own style of social work to deal with these issues and mine is to give it all when the person is with me and then not give anything when they are gone. Let it in. Let it through. Let it go. Works for me.

Now I’ll get to my point. Remember the story about the guy who got shot in his penis just after getting out of jail? I was torn between telling anyone that story and not telling anyone that story. The intervention trail I took wasn’t exactly out of the Crisis Intervention class I had in grad school. It probably would get a little heat from the ethics board at the National Association of Social Workers organization. But I did what I did and it seemed to work at the time. Still. I always wondered if I did the best thing. I also feared getting caught and having to defend myself to someone who isn’t as, let’s say flexible or creative or spontaneous and not say professional or some such word, as I am. Five years later I still let that one get to me. It didn’t go in and out and be gone. It just went in.

Later on that night I was walking down the hall. It was busy as always and all the rooms were full and the hall beds that we aren’t supposed to use were getting filled up. I make it a point not to have eye contact with people in the hall as they often ask me questions I can’t answer or make requests that I can’t fill or maybe even vent about something that I couldn’t control. I have the ability to ignore people under those circumstances pretty well so I was surprised when I heard someone call out to me.

“Hey there Mr. Social Worker.”

I turned and saw a black guy about thirty with an older woman, probably his mother. I hate to get caught forgetting people, like the lady with the dead mother and have learned to not give myself away unnecessarily.

“Do you remember me?”

“I remember your face.” Non-committal won’t get me in trouble.

“You came and talked to me a few years ago. I was on the back of a motorcycle and got shot.” The Dick Shot. Now I remembered.

“Oh yeah. I remember. How’s it going?”

“It’s going good. I’m living in Iowa with my auntie. Got a job. Going to school.
And all my parts work.”

“Well that’s good news” I said.

Working parts. A job. School. Just like I said.

“You’re a funny dude man. But you were right. I took your advice. You were right for sure.”

That’s a face I won’t forget. It was a face that had been haunting me for years and now it won’t. He’ll never know how happy I was to see him. And next time I will know him for sure. For five years I had paid some heavy dues for that night. He had been paying since too. And it all worked out…

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No Respite

Mexico

by Robert Lanz, LCSW

Keith is one of my surfing buddies from Canada. Right. Who knew there were waves up there. I thought all those guys did was ski, snowboard and play hockey, Eh.

I meet Keith at my hotel in the tropical part of the state of Nayarit, Mexico, just north of Puerto Vallarta. The waves were usually good and the water was always warm. Surf Nirvana.

While Keith’s friends back in Vancouver were struggling into heavy wetsuits and warming up in hot tubs before paddling out, Keith was donning a thin rash guard to keep the powerful sun off his ghostlike Canadian “tan.” Two joys in any surfers life. Decent waves and NO WETSUITS.

Anyway we had strayed from the beach because the decent wave equation had failed us – and for those of you that don’t surf, understand that good waves are the exception, not so good ones, the rule. We went up to the high plains above us to the city of Guadalajara where we acted like total gringos for a few days enjoying mariachi music, antique shopping and flea marketing at the Plaza del Sol.

On the road home we pulled off the main highway into the little town of Tequila. Yeah it’s a real town, surrounded by fields of blue agaves that are cooked down in distilleries into tequila. A guy I went to school with has his own brand of tequila, Patron, made here locally and in the back of my head I was hoping to run into John Paul in town. Of course the odds of that are long but it was still worth a thought.

Keith only knows me as the surfing social worker. If I ran into JP, one of the richest guys in America, the trip would turn into a Hollywood story. Not a surf story. Not a social work story, a rich guy’s story and most social workers don’t know a lot of rich guys, although having visited Keith in Vancouver and seen both his beach house and his chalet in Whistler Mountain ski resort I suspect he’s got a lot of dough too. But all that money stuff belongs in another blog. This is an ER social work blog and I’m sticking to it.

The town of Tequila literally smells of distilling agave hearts and just the vibes alone would be reason to stop for a beer and a couple of shots of cactus juice. Or maybe one of those tax free two and a half liter mini barrels of my favorite Cuervo Commeritivo.

In any case, this is an ER social work story not a day at the beach story with some drinking thrown in and a social work story needs a social worker and a patient. One from central casting would be perfect.

Keith and I were sitting at an outside table in a small cantina, finishing up our tacos and beer and some free sample shooters. What most of us would call a laid back afternoon. In a couple of hours we’d be back at the beach watching the sun set over the Pacific. The perfect end to the perfect day. Then the “patient” showed up.

From a distance my first thought was that he had been working underneath one of the many large trucks parked next to the cantina. Covered in dust and grease it appeared, well, not out of the ordinary considering where we were. Then he walked closer and spoke.

“Money. Give me some money.”

I saw Keith reaching for his wallet.

“He’s a crack head Keith. He’ll just smoke it all up.”

Keith was taken aback. He still thought the guy was a mechanic who just wanted a cold beer.

“Look at his finger tips. All burned. Look at his lips. All burned. Look at his skin turgor. He’s dehydrated. He’s a crack head.”

Of course, Keith wouldn’t know that. He’s a Canadian lumber broker who surfs. Probably never saw crack in his life. If he saw a crack head on the east side of Vancouver he probably didn’t know it.

But me? I’m an ER social worker. Always on duty. Even in the town of tequila on an otherwise perfect day….

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