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….

Dividing line

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More Gangs

Gang unit

by Robert Lanz, LCSW

Since this happened to me a lot has happened in gang culture. A lot less fun and games than used to be. Check The Mexican Mafia by Tony Rafael to see where this has gone to lately.

Gang behavior is so insidious. But this was a humorous night and I was on a role, having to combine the insidiousness of gang violence with a twisted sense of humor. Psychosocial hardball so to speak and not a lot of players are up to it, but tonight, I was. It truly was one of those nights where nothing could go wrong. Well, not with my end of things anyway. My delivery was crisp. My lines were tight. I was on…

Julio and his brother and two friends were from gang A. Gang A has a major problem with gang B and they fight a lot. They fight at school on those rare days when they actually go to school. As part of their code they fight on neutral turf if they run into one another. They fight on their own turf if one of the other gang members is foolish or brave enough to go onto their turf. The guys from gang A know if they go to gang B’s area they will get beat up. The guys from gang B know the same. They also both know that if the bad boys from either side come onto their turf with any sort of numbers they are looking for the home team, if not for a full on attack, at least for a little snipe. Sort of a West Side Story with a different soundtrack, live bullets.

Well tonight, Julio, coming form the dysfunctional family that he did, ended up staying in a local motel with them after they were evicted from their house on their own turf. The problem was, they moved into a motel on the fringe of the other team’s turf and the other team saw them because Julio and the boys didn’t have the sense to stay indoors and be low profile on hostile ground. Maybe they would have felt too much like wimps if they would have done that. Maybe they couldn’t stand another minute in the motel room with their parents, I don’t know.

What I do know is these guys are never going to score big on Jeopardy. Not only did they move onto the turf of a gang dedicated to trying to beat them up, they even went so far as to have some of their friends come over. Local gangsters felt that was a direct affront to their honor so they called all the homeboys, loaded up several cars, collected all the blunt objects they could find…baseball bats, car jacks, 2×4’s, what ever it took, and went to the motel where they caught Julio, his brother and two friends out in the open. Then they had batting practice with Julio having his face crushed, a gang bangers home run equivalent. For all the possibilities, it was a wonder that no one was killed or more seriously injured. Julio’s brother took a glancing hit on the head– home with no stitches and a small Band-Aid. Their friend Mike took a hit to the head too and also required no stitches…home with a larger Band-Aid. The third victim didn’t even have to come to the hospital. But Julio got it big time. Facial lacerations. Multiple facial fractures. Eye damage.

Julio, of course, had no health insurance and had worked his way up to about three thousand dollars in the ER alone. What with CT scans, X rays, plastic surgery and the like, this was going to cost someone a lot of money. Let’s see, who can that be?

The state of California has a special fund to pay for victims of violent crime. To be eligible, all the victim has to do is cooperate with law enforcement and spend about an hour going to city hall or a local police station and filling out a form. Most victims without insurance don’t do it so like everything else, in some way, the guys that have it together financially have to take care of those that don’t, even when those that do have absolutely no control over those that don’t. How we ever got into this position of having total responsibility and no control, I’ll never figure out. Anyway, I’m digressing and this was supposed to be fun.

To set the scene I will continue the digression a little longer because it is important to understand the context. Humor is nothing without context. Latino gangs, almost exclusively only have problems with other Latino gangs, unless they are in prison then they have problems with everybody but on the streets, if you are not in a Latino gang, you will probably not have a problem with a Latino gang. The kids look upon gang membership as a team sport and if you don’t want to play they won’t make you get into the game. When they are not involved in gang activities they seem to be nice enough and during the 7 years I worked in juvenile hall and forestry camps, the Latino kids were some of the best I ever had. They will swagger around like any teenager. They will lie to the police. They will brag about how tough they are. But they have respect. When they come to the hospital they are usually good patients and they get along good with staff despite their injuries, hostilities and seemingly antisocial behavior. They frequently joke and are playful if their injuries are not too severe.

Julio and his homeboys were typical in their behavior. They compared wounds. They laughed about the events that could have gotten them killed. They were supportive of Julio and cursed the other gang for beating up on an innocent 14 year old. They plotted revenge right in front of me. I knew how to be with these guys because I had worked with gang kids for years. I knew how to act around these guys because I knew guys from their gang when I was their age. I knew how to act around these guys because I had grown up hanging out with guys from their gang. And I knew before the night was over and they all went home, I was going to blow their minds. I have, on my office wall, as a constant reminder of other days, an 8×10 black and white photo of me, dressed down in gangster clothes, in front of a big wall that is covered with graffiti with the central focus being the name of their gang, FROGTOWN, in fancy gang lettering prominently painted with the name Flaco over it and Alfredo written off in the corner. It was a photo I had for over twenty years, taken when I was a probation officer and still living in the neighborhood I grew up in. It was a private joke between me and some of the gang kids on my caseload, my own badge of courage. I got a lot of mileage out of it when I was a probation officer and knew I would tonight too.

After I had ensured the boys were stable and safe, I started to loosen up and told them I was living near their turf and that I had actually lived there as a kid too. They were looking at me just a little sideways, finding my old guy stories a little unbelievable so I escalated and told them more stories about some of the guys who were probably their uncles or parents. They laughed. They went to the waiting room and found their parents so they could hear the stories too. Then the parents laughed at the stories but they told me they thought I was joking to make the kids feel comfortable after their evening’s difficulties. I couldn’t resist a good punch line so I set them up.

“What would it take to convince you that I was a homeboy?” I asked. They laughed again, thinking I was just joking.

“Really” I said. “What would it take?”.

They drew a blank. They didn’t know what to think. I grabbed one of them and made him go to the office with me and when I showed him the picture he was convinced. We went back out to the busy waiting room and he told the rest of the guys and they all wanted to see the picture too so I let them and I got more respect. Then they went and got their dad so he could see the picture too. I took him into my office alone, showed him the old photo and then told him the truth, that I had done it as a joke with some of my gang kids when I worked for the probation department. Dad laughed. Dad laughed harder than he should have. Dad laughed really hard.

“Alfredo was my cousin and I knew the real Flaco,” he told me. “One’s dead, the other’s in prison.”

He promised to tell Flaco next time he wrote to him in prison or when he got paroled, whichever came first about the old white guy in the gang photo. Then he laughed some more. The kids were laughing too. I never did understand what was so funny. Neither did my staff.

We sent Julio down to the county hospital where he could get to see a plastic surgeon, an ophthalmologist and a facial bone specialist for about fifteen thousand dollars worth of repair. Julio was the only one who wasn’t laughing. He tried to but it hurt too much.

Dividing line

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Team Player

Team player

by Robert Lanz, LCSW

There are some guys on the trauma team that are more or less outliers, some of them so far out that most of us don’t even think of them as part of the team. In fact, they are so far out they probably don’t think of themselves as being part of the team either and that may be the bad part for these guys. If you have to suffer the trauma of being on the trauma team then you ought to know it. You ought to have some defenses built into your day like the rest of us. You ought to have a debriefing support group or something like we do.

The cops do it. So do the paramedics and firemen. The doctors and nurses and the rest of the staff, even down to the janitors and secretaries, do it because we all know they are part of our team and we watch out for each other. We are all an obvious part of the team that deals with the treacherous outcomes of mistakes, bad luck and lame decisions that bring people to the ER.

Those guys who drive the tow trucks are sort of victims themselves, having to clean up after the paramedics have left the scene of terrible accidents or even having to watch while the patient is extracted from a crushed vehicle. One time they even called the paramedics when they found a severed finger in a car they were towing and didn’t know what to do with it. With all the other trauma, the cut off finger was overlooked, a reminder, for the moment, the driver is part of the team, even if unwillingly.

Let me digress for a few moments. Although it wasn’t in the policy and procedures manual and most folks didn’t think it was necessary and some folks even thought it was an invasion of privacy, none of that mattered much to me. One of my professors taught me to always consider the possibilities of the unseen victim. Lucky for me I had a good relationship with the cops who came to the ER. Over time they began to understand when I asked questions about an accident they were investigating they knew I wasn’t just indulging in some voyeuristic fantasy.

For me, the unseen victim was the guy who survived the accident unscathed, often the guy who was the innocent one in the tangle of metal and asphalt. If he wasn’t injured and he wasn’t at fault, the cops just took a statement and maybe helped him call a friend to get home while his car was towed away. Hey, how could he be a victim? He didn’t get hurt and he didn’t get busted and the other guy got squashed and taken to the trauma center . He goes home seemingly safe. But I know that a lot of them aren’t safe. They’ve just been in a life and death situation and not addressing that is incomplete medicine.

The literature on traumatic stress reaction shows you don’t have to be the actual victim to end up traumatized. You just need to be close to the action to suffer it’s traumatic effects. Two issues come into play. The closer you are to the center of the violent act, the more it will effect you and the more closely you are connected to the victim, the more it will effect you. Bad luck for a lot of guys is that they are almost never emotionally connected to the other guy and despite being in the actual center of the trauma, they get overlooked, kind of like the finger left behind and found by the tow truck guy. Pretty minor it would seem, compared to everything else.

Imagine, if you can, that you are the guy that finds the finger or you’re the guy that’s been in an accident with the death of a stranger and no one gives any thought to what that may do to you emotionally. You don’t go to the ER so none of us see that death stare look in your eyes or that nervous tremor. No one died in your car or no one died at your house so the police chaplain doesn’t come out to see how you are doing. Nope. This is emotional aftermath that you will have to deal with on your own. Unless, the social worker in the ER who has the good relationship with the cops asks for your phone number and the cops, who have learned a little about that clinical judgement thing, don’t have to think twice about giving out that confidential information. They know if it gets back to their watch commander or the chief that they shared confidential information they can say,

“Hey, Bob the social worker told us why he wanted it and we thought it was a pretty good reason and you would too if you talked to him, do you want his number?”

Lucky for me a lot of the watch commanders used to be street cops and I knew them too and we had history. Enough history that no further questions were necessary.

So, at first, it probably seems strange for the unhurt guy to get a phone call from the ER social worker who wonders how he is doing. Since most people don’t even know there is a social worker in the ER and are clueless about what we do until we do it, I usually opened with an introduction that included that I had spoken with the police officer and he thought I should call and see how you were doing. Then I would listen for answers that would guide my intervention. It’s that clinical judgement thing again. Being able to pitch a perfect stranger about mental health issues is a difficult skill set to acquire. Thoughtfulness and practice I guess.

Anyway, what usually happens is that the person rambles a little, then gets more focus, re-frames things a bit then listens to my pitch about normal reactions and what to watch out for and he thanks me for calling. I give him my number and tell him a SW will answer 24/7 if he has any questions. Sometimes the normals move into ‘uncomfortables’ over time and I want us to be there just in case. This usually works pretty well and the unseen victim realizes he has been seen and tended to and now knows part of why there is a SW in the ER all the time.

That’s why I started calling the tow truck driver guys. If the cops mentioned that the accident was horrendous or that there was a death or the tow truck guy had to hang out while the paramedics did an extraction or something happened like that finger incident. Most of the time they seemed OK and found it interesting that I would even call and check on them. Most of the time they had found their own way to dodge that emotional bullet. At least I hope they did. Kind of hard to tell on the phone and they were a tough crowd, at least on the surface, so maybe they were OK and calling them was just overkill on my part-oops, I probably could have been more sensitive in the way I put that.

So, one night I had a special request for the tow truck guys. One of my regular homeless alcoholics, living on the street in his electric wheel chair had been brought in, again, when he misjudged a curb while going about as fast as a guy could go in an electric wheelchair. He did the perfect face plant, also again. He either thought he was going to zip up that ramp and struck the curb instead or he though he was going to zip down that ramp and went off the curb instead. Didn’t matter much I guess. A drunken face plant is a drunken face plant regardless of the actual mechanism of the injury. Didn’t matter much to me, again.

What did matter to me was that last time the homeless drinker in the chair came into the ER with a face plant, again, was that after he sobered up enough to get going he had nowhere to go or any way to even get to nowhere because his chair was lost in the shuffle. Cops didn’t have it. Paramedics never saw it. Maybe it was still back at the crash site. Maybe someone stole it, urine stench and all. Anything can happen in the street. Luckily for me, after four hours of phone calls I finally got a family member to drive thirty miles at midnight with an old chair he had in the garage and take the homeless guy out of our hair. I thought it was particularly skillful of me to offer gas money when the family member said he didn’t have any. Twenty bucks of my own dough and worth every penny. Still I didn’t want to go through that again. The twenty bucks was the easiest part and I’d probably not be able to spring that trap another time.

So I started again with hope and a prayer. I called the paramedics to check on the chair. They thought the cops had it. I doubted that as the chair weighs a couple of hundred pounds and it was unlikely they would have thrown it in the trunk of the police car. I was right. The cops had called the tow truck to haul it away. Great. I knew where the chair was and I’d have to get the chair to get rid of the patient and all I had to decide was how much of my own money I would be willing to spend to make this movie end well. Like a lot of things it always comes down to the two currencies in life. Time and Money. How much time would I spend to avoid spending my money. How much money would I spend to save some time. Should I start trying to get his family again or just whip out my credit card and pay the tow guy to get the chair back? The cops thought it would be about a hundred bucks. Man I was stuck. No money from the hospital, so I’d be on the phone for hours again or use up half a nights pay to avoid the aggravation. Time/Money. Money/Time.

I called the tow company to see how much it was going to cost. Time won out over money.
Well, they had his chair and it was $160 to get it back. The guy heard me groan.

“Dude. There’s nothing I can do.”

“Yeah, I know. I just gotta get this patient home.”

“You calling from the ER?”

“Yeah. I am.”

“Is that social worker guy down there tonight?”

“Yeah.”

Before I could tell him who I was, he hung up. I called back but didn’t get an answer.  Damn. Time/Money. I started calling his family again.

Fifteen minutes later the secretary called me up to the front. She told me there was a guy out there from the tow company and he wanted to see the social worker guy.

I walked out and there was a giant flatbed tow truck with an electric wheelchair strapped down, dead center, just like a crushed car would be. When I approached, the driver asked,

“Are you Bob, the social worker?”

“Yes, I am.”

“I brought the chair.”

He tilted the flatbed and winched the chair down to where I was waiting.

“No charge” he said. “I owe you. Last year you called to see how I was doing after a big crash on the freeway. I was OK but I appreciate you thinking about me.”

And then he drove off.

Time/Money.

I took the time and didn’t have to spend the money.  Works for me….

Dividing line

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Rose

Drunk old woman

by Robert Lanz, LCSW

Sometimes I wished I worked at a bakery like when I lived in Park City. After that last doughnut came out of the cooker and those final brownies were wrapped, I changed into my ski gear and went and had fun. I never dreamed about cookies or apple fritters. I never gave a thought to the sour dough bread on the shelves I had helped prepare. Not a thought about the bakery until I passed it on the way home to catch a nap before returning at two in the morning. Never a thought.

I should have known not to bring a patient home with me. I should have known to not be influenced by a woman who was weak and under the control of alcohol. I should have just left her there in the ER and ignored my feelings and gone on home alone like I always do. It’s not good practice to let things like that happen and a person with half a brain could see doing such an act would only lead to problems, sometimes big problems…sleepless nights, guilt, embarrassment. There are a lot of reasons not to fall into the trap some patients seem to set. They can find your weakness, drive a wedge into your soul and make you think thoughts you don’t want to think, say things you don’t want to say and do things you don’t want to do. I should have known after fifteen years it would only lead to grief and I did it anyway. In the morning I was sorry.

Rose is seventy-eight years old and she drinks. She drinks way too much and has for a number of years. She is getting worse and a few days ago she decided to leave the safety of her retirement community because they wouldn’t permit her excessive drunkenness. She hit the streets with about a thousand bucks and like Nick Cage in Leaving Las Vegas she seemed hell bent to finish herself off before she ran out of money. She had a good start the day she ended up in the ER, smelling like a diaper pail and looking like she had been on the streets a lot longer than the three days she had been. Her hair was matted, her face was dirty and my eyes watered from the acrid ammonia smell of the urine that soaked her clothes. I was ready to hate her, for having left safety and moved to danger at her age, letting the alcohol do the thinking for her, and I guess, the acting. She was found down in the street, unable to get up, clutching a half empty bottle of vodka. The paramedics told me she had a lot of money on her and that she was homeless. That’s a rare combination; especially at the end of the month when funds get a little thin while the drinkers wait for their “disability” pay. Rose was going to be an enigma. I knew that from the start. I didn’t have any idea I would take her home.

She had no family, no friends, no place to stay and she thought she lived someplace she didn’t. She had no keys in her purse so I knew she had no residence. She still had her money despite her obvious intoxication so I figured she must be pretty smart to fight off or fool the predators that would be more than happy to beat, rob and rape her when she passed out in the bushes.

She wasn’t crazy enough to lock up unless she wanted to be and she didn’t. She wasn’t gravely disabled enough yet but she was going in that direction full speed ahead which is truly a scary idea at her age. She wasn’t suicidal or homicidal in the sense that I could have the police put her away for a few days. She wasn’t quite bad enough yet to take away her rights. Not yet. I knew she was destined for worse things but there was nothing I could do about it. It was getting on to midnight and it was cold outside but Rose had sobered to the point of being legal again and she wanted to take a cab to the home she no longer had. She was holding enough money to go in search of it though and I knew that’s what she would do.

I called the psychiatrist on call on the off chance that he would get out of bed, drive across town and fudge the rules a little to declare Rose gravely disabled so we could lock her up and detox her. He was angered at the idea. I thought maybe we could call her regular doctor and see if she would admit Rose for detox but Rose didn’t want to hear any of this and the ER physicians didn’t want to wake another doctor for an alcoholic who didn’t want to stop being one. By now, it was pretty clear that the only person who gave a damn about Rose was me. In the big picture, that would probably give a normal person a clue they needed to reevaluate their position but I’m not a normal person.

“I can’t let this patient go out. She’ll die in the cold or get killed and robbed. I’m not letting this patient go so she can die on my shift,” I yelled out in a crowd, hoping that one of the docs or the charge nurse would offer some suggestion. One did.

“When’s your shift over?” I was asked.

They had made up their mind to send Rose out into the night and given all that she had done with her life, especially over the last few days she probably deserved whatever fate she got. But not on my shift.

“It’s over right now, I’m out of here.”

“And so is she” I heard as I went to lock up my office.

Rose took a cab to nowhere but in my heart I brought her home and put her to bed where she kept me up all night with nightmares of old women that looked like my mother and grandmother being raped and murdered in the street.

The feelings haunted me the next day and the next night Rose was there again to keep me from a peaceful sleep. I knew we had done wrong to let her go but there was nothing else we could do. That didn’t matter. I knew I would see Rose again and it would be bad.

After an anxious and sleepless weekend when I came back to work three days later, Rose showed up with the paramedics. Found down again intoxicated. The secretary pulled out an old chart from the previous day when she had left following another drunken visit to the ER but at least this time she didn’t get sent out into the night. What she did get was a two thousand dollar workup; CT scan, blood work, the works. She had a broken nose and enough abrasions on her face to make everybody uncomfortable but not uncomfortable enough. The psychiatric nurse that evaluated her at four a.m. didn’t think she was crazy enough, disabled enough or self destructive enough to be locked up. Maybe when he went home he had nightmares too.

Anyway, tonight Rose didn’t smell any better than she had the previous visits. Her clothes had been changed and already were as dirty as her old ones. Her blood alcohol was three times legally drunk and she could still walk. But despite all this, when I walked into the room her face lit up and she said, like we were old friends,

“Hi there Bob, remember me?”

“Yeah I do, Rose. You caused me to lose a lot of sleep”.

She cried and asked what she should do.

“Get off the streets, get off the alcohol. Get a life. Grow up. Go to detox. Go to meetings. Move into a safe place”.

“OK, I will.”

It took about three hours to battle my way through the nightmare of insurance companies, admissions clerks, accepting physicians and transportation but the arrangements were finally made. The ambulance came to take Rose to the detox center. As she was being rolled out the door she turned to me and asked,

“If I do all those other things will you do one thing for me?”

“Probably” I answered.

“Take me to dinner when I’m sober”.

‘I’d be honored,” I replied.

And this time, I won’t be taking you home…

Dividing line

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Death of a Princess

Anorexix blonde edited

by Robert J. Lanz, LCSW

At one point in time she had been the embodiment of the California Dream. Lustrous blonde hair and sparkling blue eyes. Golden tanned skin and perfect white teeth forming a movie star smile. She had the robust body of a cheerleader, and on one New Year’s Day, she waved and posed in that famous parade as millions of people looked on in adoration of her physical perfection. And in all likelihood, since it never seems to rain on Southern California parades, those millions idealized the climate, too. Everything in the young princess’s world was perfect.

I imagine things would be different now, but in those days, knowledge of the behavioral manifestations resulting from some parent/child conflict, some genetic predisposition or twisted addiction were less well understood. What I understood was that, at some point, the princess’s fortunes had changed markedly. The patient was no longer on her way to fame and success and all the things everyone imagined for her when her carriage passed before them on that January morning.

Nope. Now she was “upstairs” dying and someone called down to the ER for me to come up and take part in the process. The intensive care unit, on the second floor, was a long way from that flowered float that carried her down Main Street. Whatever was going on in her mind was a long way from all those California dreams that come from having a centerfold-quality body. I’d seen centerfolds. And yes, I’d seen plenty of dreamy California girls at the beach. I was also familiar with the literature on eating disorders and seen some of the photos of extreme cases. But the women who suffered from them seldom came through the ER. When they were hospitalized, their doctors usually arranged for direct admission, so it was rare for us to ever see them in person.

I can keep a game face better than most, and in thirty years of delivering the worst kinds of news to some of the best kinds of people, it wasn’t hard for me to mask my feelings. In my job, that’s a good skill to have. People are always aware of my concern, but uncovering the depth and exact nature of my emotions involves more of a cognitive process. Most of the time the people I’m working with can’t tell when I’m incensed or disgusted or terrified, so sad I want to lay down on the floor and cry or fall into the arms of the ICU charge nurse to be held and comforted like a baby.

That’s about the way I felt when I came into the intensive care room where the patient, her doctor and family were all waiting for me. The sight of the princess, all hooked up to machines and IV’s caused me to catch my breath, a very rare occurrence. I could probably remember another such occasion if I searched the darkest part of my brain where horror is safely tucked away beneath multiple layers of something else. But why would I want to go there and revive those memories? Remember when you walked in and saw your parents having sex? Yeah, I don’t either, and there’s a reason for that: psychological self-preservation.

But self-preservation was totally absent there in the ICU. As I rocked onto the balls of my feet, tried breathing like a normal person and got my bearings, I saw that there was nothing normal about that room. The multiple IV bags with tubes going into arm veins and neck veins and back of the hand veins. Veins that were so prominent that even the most inexperienced phlebotomist could hit them on the first try. All skin and bones, making for very prominent veins.

More tubes. Some in and some out. A decent-sized nasogastric tube went up her nose and down her esophagus for “feeding” the princess who had long ago decided that food was off her list of things to consume. She may have had a more discrete feeding tube sewn into her stomach. I don’t know, as that part of her, what there was left of her, was under the sheet. Looking under the sheet might prompt more thoughts I didn’t want to entertain. The last tube was the ever-present urine catheter used to measure fluid output. Everything coming in gets measured. Everything going out does, too.

The concerned parents were at the bedside. One of the brightest doctors in the hospital was at the bedside. Some of the most skillful nurses in the hospital were at the bedside, and now one of the most experienced social workers in the hospital was in the queue. All of us stared at the patient in disbelief.

“What happened to our daughter?” the parents were likely wondering. “Is there anything else we can do?”

The normally objective nurses might have thought, “She used to be the girl I once fantasized about being.”

The doctor was probably thinking, “How did we lose control of this situation? There’s nothing left to do but call in the social worker.”

I was thinking, “I wonder what they expect me to do?”

When doctors and nurses and families are about to enter the totally helpless zone, the zone where no one is quite sure what to do, they call in the social worker. It’s one of those times when everyone knows what is going to happen, but no one knows what to do about it. The family looks at the doctor. The doctor looks at the patient. The nurses adjust the tubes. The patient now weighs sixty-two pounds and her bones stick out like those of the women in documentaries about German death camps during World War II. The once sparkling eyes are sunken deep into her face, colorless, barely there. A fine dusting of delicate little hairs called lanugo covers her face and body, a product of her whacked-out starvation body chemistry.

She’s slipping away right in front of us despite all the IV’s containing whatever is running into her body. As with any other grave illness, sometimes you can only watch as the patient slowly loses her heartbeat and fades from existence. A key component in that fading process is denial. For the princess, it most likely began about sixty pounds ago, when she stood naked in front of a big mirror looking on in disgust at a body she perceived as overweight rather than as the slender one she really had. If she were asked to hold her hands out to demonstrate the size of her hips, she would probably be off by at least fifty percent. A very strange disease indeed.

But none of that mattered. With all of our rebalancing interventions we could slow the death process, but not stop it, because the damage had been done. The princess was now on the death list, one of the ten percent of anorexic patients who would lose the battle.
I got beeped back to the ER before it was over. The lost battle against electrolyte imbalance, infection, hypotension and inevitable cardiogenic shock was in its final moments. It was all going wrong, from the perfect life to this almost perfect death, ebbing away as we all watched in excruciation. Total excruciation.

Back in the ER, I had other serious matters to attend to, so I put the sad princess’s death in my store room for dreams that have died. I needed to make room for the dreams that were still living, but it was also important for me to keep that kind of sadness out of the house where most of my life was lived.

Dividing line

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