Another Reason Not To Smoke

Gas explosion 2

by Robert Lanz, LCSW

An old motel not too far from the hospital, a roll of duct tape, a pair of pliers, a pack of smokes and a fifth of Jack Daniels – the only thing missing in the list of props is a depressed old guy who would soon be dead. Remember the statistics on who is most likely to take their own life: old white men living alone and drinking. Well, we’re all matched up now so let’s go to the script.

Depressed old guy rents a room at the old motel that still has the gas stove in the kitchenette. Depressed old guy puts duct tape over the window frames and goes out for a bucket of ice from the machine. When he returns with the ice he puts a couple of cubes into a glass and adds a double shot of the whisky, knocks it back and pours another, thinks a moment, then goes back to the duct tape and tapes up the door sill and jams. No use stinking up the parking lot he thinks.

He then pulls out the pliers and twists the connecter that ties the gas stove to the gas line and turns on the valve –whoosh, the gas escapes into the room while the depressed old guy takes a seat on the couch and pours another drink. The pouring and whooshing continues. Despite his level of intoxication he remains melancholic, sniffs the gas, puts more ice into his glass and pours another shot of JD.

Over an unknown period of time, maybe an hour or so. according to the night manager of the old motel, he continued drinking apparently thinking (and I could be wrong about this) all that natural gas from the stove would eventually kill him painlessly. In a way, I guess, it did. But not the way he thought.

The fire investigator thought the depressed old guy grew impatient as he became more and more intoxicated. He most likely pulled out his smokes and his ancient Zippo lighter. When he rolled the little wheel against the flint a super whoosh blew the walls right out of the motel and flashed-burned the depressed old guy. He was found, unconscious, but alive, but seated on the smoldering couch which was now located in the parking lot of the business next door.  He was covered in white powder. Apparently someone (no one knew who) sprayed him with a fire extinguisher. Probably a good thing he was still unconscious: he would otherwise be in a lot of pain.

Sometimes, even though a severely burned patient comes to the hospital alive and breathing, we still can’t save him. Too much damage. When flesh gets burned, the underlying tissue swells from the body fluids being released. Dermis destroyed by burns is the perfect storm for infection. Third-degree burns imply that there will be areas of first and second-degree burns as well. Third-degree goes all the way down to the fat, or worse, to the bone: if a victim is lucky, the nerve endings have been burned away.

With this level of destruction, every patient I have ever seen with burns like this old depressed guy had (except one) were in such acute pain that they begged for death or unconsciousness. This old depressed guy’s nose hairs were burned completely away so we knew his lungs were equally damaged to the point we could barely get a breathing tube into them. While a machine breathed for him, his muscle tissue started breaking down, and once into circulation in his blood, released myoglobin damaged his kidneys. The heat from the explosion burned his trachea to the point where no machine could save the life the depressed old guy wanted to end. Simply too much damage. In the ER, he died.

He had no I.D., so I never knew who he was. ‘John Doe #2634-87,’ I guess. He looked really bad, but he did get what he wanted. With the police present, the coroner took the  body and that was the end of it for me. Except for the nightmares.

Somehow, a guy should learn how not to do that: not be afraid of any of one’s feelings, that is. Let them in, let them through, and let them out. But sometimes the passage is simply too treacherous, and they linger forever…

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Butt Burns

Grill marks

by Robert Lanz, LCSW

Lightening things up a little this week…..

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“Hey Bob. Can you go in room nine and talk to that kid and his dad? He’s got a weird burn pattern on his butt.”

After a while in the ER it becomes almost obvious that some injuries are seasonal. First week of football practice? Call ortho.  Start of ski season? Call ortho — and warm up the CT scan.  Summertime? Forest fires in the local mountains. (Our paramedics and firefighters get fall and burn injuries.) Christmas? Drunk drivers. And the one that brought room nine to my attention tonight: October chills bringing on old wall heaters.

This is California. We turn off the gas to heaters in our homes around the end of April and turn it back on in October or later. That’s half a year for kids to forget simple things like the fact that in their trendy old Craftsman homes, heat comes from registers on the floors or walls. In those six months, kids either forget how hot the registers get or they grow to be more mobile and can’t seem to avoid scooting onto the hot metal floor registers before their parents can stop them. The result of those lapses could result in grid-pattern burn (matching the pattern on the register) on kids’ hands and feet and sometimes even their knees.

Hardly child abuse or neglect.  Though that’s possible. Usually those kids from Craftsmans showed up at the ER with both parents, and seemed to take comfort equally from mom and dad. (The parents had the same six months to forget about the heater.)

I suffered one of those butt burns myself, just out of grad school while living in a funky old house in Echo Park (now hip part of L.A.’s music and movie scene.) The house only had one gas heater to heat the whole house — not that difficult in L.A. weather, even in the winter. (I even had a gas faux fireplace with cement logs, if it ever got that cold.) And one night, it got that cold. I set the wall heater to its highest level. I got out of the shower and stood in front of it, shivering (naked of course, holding a big towel in front of me, enjoying the warmth on my bare back. Enjoying it, until I dropped the towel. Most social workers I know don’t fantasize about being engineers or physicists and I’m solid on that list myself. Perhaps if I had studied harder in my undergraduate science, technology and math classes I would have understood the mechanics of the butt burn move that was to come.

If your rear-end is only a few inches from a wall heater and you bend over very quickly, your ass will press right on to the heater: instant pain, and a grid-pattern burn on your derriere that matches the pattern on the heater guard Pretty lame. But as the president’s right-hand man used to say, ‘never waste a crisis.’ Or in this case, a butt-burn.

At the time, I was working in juvenile hall, Here I was on my shift, with burnt skin and grill marks on my ass.  My secretary asked why I was walking funny. I turned to tell her the story of how it happened, but being young and impulsive, when I opened my mouth, out came this tale:

My friend Danny and I were at the Pancake House in Hollywood after some serious carousing at a couple of blues clubs. A food fight started (and we weren’t participating) that turned into a fist-fight that turned into a near-riot. I resisted the impulse to pull out my probation officer’s badge and try to break up the melee. Clinical judgment screamed out to me: ‘Too late for that Bob — get out of here.’ With about twenty people brawling it looked more like a biker bar than the International House of Pancakes. We made a beeline for the back door through the kitchen. When I tried to run past the huge Samoan pancake chef, he put a giant shoulder into my gut, stood up and lifted me off my feet and I sat me right onto the waffle iron.

It was about that time in the story that I pulled my pants down and said to the secretary, “Look what happened.”

There it was, the marks on my butt cheek looking very much like a Samoan-induced waffle iron burn.Repeating the story over time, I kept embellishing it, but always kept the same ending and showed-off my right butt-cheek with the cross-marked pattern. Hell, I was almost a little bummed out when I healed all up. No one, until now I guess, ever knew the true story of the injury, the fiction being a much better presentation than the facts.

So I walked into E.R. room 9, introduced myself to dad and the boy and told them a social worker was required to see all children coming into the E.R. with any kind of burn. I already surmised what happened, but legally I had to hear it myself. The kid showed me his grid-pattern burned butt cheek and gave sort of a frown. It wasn’t funny to him and I figured he probably wasn’t old enough to massage this painful experience into a humorous one. I hoped he someday might acquire that skill. (I’d be happy to help if he ever asks.)

The child said, “I was standing in front of the heater after my bath and I dropped the towel. When I tried to grab it, my bottom went against the heater and it burned me.”

I looked at dad. He shrugged.

“Sounds like an accident for sure. Case closed.”

And dad says, “That’s it?”

“Well. I lived in an old house too.”

If I still had the marks I probably would have compared butt cheeks and maybe at that very moment the kid would have learned the valuable skill of laughing at pain.

“That covers my part. The nurse will come in and put some Silvadene on it and tell you how to watch for infection. No big deal.”

Dad said, “This won’t ever happen again.”

“Yeah. I know.” I could say that with all sincerity.

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Murder

Evil eye

by Robert Lanz, LCSW

Maybe the police shouldn’t have brought him into my office. I really didn’t need to see him in up close. I didn’t want to know him, speak to him, hear him, or in any way have to think of him as a person. Not after he killed a child. But the cops showed up during their investigation of the child’s death just like they’re supposed to, and there wasn’t much I could have done about it. No matter how well you know the officers that come in on a regular basis, and no matter how much you like them, working with the police can have its downside. They are so used to bringing in victims and sitting around my office with them, they probably didn’t even think about it when they brought in the young man who struck the blow that took a child’s life.

I wish I hadn’t looked into his eyes and seen what I saw. It would have been so much easier if he had just been locked away, given a brief trial and a long sentence. I didn’t care. I just knew I didn’t want to meet him. I sure as hell didn’t want to come to think of him as a person in any way.

He was so young. Not nearly as young as the little girl he killed of course, but young, still in his teens. Too young to have his life take such a harsh turn. Too young to have his mother worried about him locked up somewhere where child killers are of the lowest status. Too young to have to deal with the cold reality of prison life every waking hour, maybe even in his sleep, until some way or another he could find a way to make it stop. Too young to defend himself against the really hard guys, who for once in their lives, could claim some moral superiority, beating this child killer senseless and sexually assaulting him whenever they wanted to. He would be a defenseless kid, just like the little girl he hit so hard in the abdomen he broke an artery that slowly bled and bled until there wasn’t enough blood in her to sustain life.

Baby-sitting is a difficult job. Baby-sitting for the woman you think you love may have been too much to ask of an eighteen year old who, in many ways, was still a baby himself.
“I couldn’t make her stop crying”, I heard him tell the sheriff. “I talked to her. I held her. I told her to stop and I yelled at her. She wouldn’t stop crying. She just kept crying, and finally I punched her in the stomach and put her down on the couch. After awhile I felt bad and I was going to give her some ice cream but she wouldn’t wake up. She was cold. She was sort of blue. I tried to warm her up, but I couldn’t so I called her mother at work. When she came home, I guess it was too late.”

It was, but just barely. The little girl was still alive when she got to the ER. Her pulse was weak and her breathing was shallow. Her blood pressure was so low, she had turned cold and blue. The trauma team took her to the operating room, gave her transfusions and found the bleeding artery and tied it off, but it wasn’t enough and the little girl died. We were too late by about five minutes. Five minutes. If only he had called sooner. If only the mother had come home sooner. If only she had told him to call the paramedics. If only he had hit her somewhere else. If only he had hit her a little softer. If. If. If. If. If only the police had taken him somewhere else, I wouldn’t have gotten to know him.

Before I came face to face with him, he was an evil young man—a child killer who took the life of an innocent little girl. After I met him, he was still a killer, but he didn’t seem so evil. He seemed scared but also sorry as he cried and he begged for death to somehow come and find him. Maybe he knew in his heart the terrible things that lied ahead of him, or maybe he had genuine remorse for what was behind him. I couldn’t really tell, but when they took him away I watched, glad he wasn’t my child. I don’t think he planned to do wrong and I don’t think he wanted to do wrong. He just lost control and wrong happened. And nothing will ever be the same.

Later that same night, there was a guy I did want to meet. I wanted to meet him because I knew exactly what he did and I wanted to hurt him. I wanted him to show up five minutes too late to save and I wanted to watch while the last breath went out of him. I wanted to watch while he turned blue and gasped for that last breath that would never come. I was in a rage over him, and he didn’t even kill anyone. Not in the legal sense at least, but he did kill something else. He killed innocence, and he did it on purpose. He planned it, he carried it out. He knew what he doing and had a long time to reconsider his actions, but he didn’t.

The twenty-eight-year-old student he chose wanted to be a virgin when she got married, because it was very important in her culture. She didn’t want to get married until she finished medical school and her residency. She was working hard and saving a lot of the great things in life for later, when her studies were behind her and she could devote the necessary energy to those great things. When we talked after her exam and collection of evidence, I was struck by how little she knew about sex. Probably not a lot more than she had been learning in her classes. That didn’t matter, she explained, because she was saving the physical part of sex for a later time. A special time with a special man. The only man who would ever know her that way.

But another man didn’t want her to wait because he didn’t want to wait. She learned about the physical part of sex on the greasy floor of her carport where she was pinned to the ground, hit, bit, choked and forcibly raped by a person who had wanted it that way. The night turned out exactly like he planned it. Exactly like he wanted it. He left home that night with a plan to perform an evil act, knowing that if he ever got caught and convicted, he would do less time in prison than the child killer. He would probably brag about what he had done, and no hardened convict would try to bend him over and take him as his prison lover. He would probably get out after a few years of lying around his cell thinking what a cool guy he was, then he would go on to commit more evil acts.

Unlike the first bad boy of the night, this was a guy I would like to have met. And I wouldn’t have wanted the police to be anywhere around when I did.

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Panic Attack

PANIC-ATTACKS-facebook-1

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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