Butt Burns

Grill marks

by Robert Lanz, LCSW

Lightening things up a little this week…..

“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. Te 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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The Student

emergency-room-300x199

by Robert Lanz, LCSW

Graduate students in the field of social work generally choose a specific area of interest to specialize in. The students select their specialty and then apply for an internship that reflects that specialty. Those students with a predisposing personality in which they are comfortable (or at least think they are) working with the sick and dying often choose to work in hospitals or medical clinics. Life is markedly more acute in hospitals than it is in most social work agencies and nowhere is that more obvious than in the ER. Because of that acuity, the students spend the first months of their hospital rotation ‘upstairs’ where the acuity moves at a slower pace and there is plenty of support around to help take up the slack during the learning process.

In the Emergency Room, especially at night, the only support staff for the students is the social worker on duty. The good part about that is they get a lot of one-on-one and have the opportunity to see an experienced social worker deal with the worst events at the fastest pace. Of course, that can be intimidating. Most of the students survive but very few of them want to specialize in working in the worst and fastest zone. Those that do, for whatever reason, are predisposed to welcoming a challenge. Some of them may start out thinking they won’t like this work, then learn to be good at it and decide to pursue it. I like to think that for some of the students, this is partly my fault.

Most students share the same fears when they start out. Most fear that they won’t know what to say to a patient or family when they approach them at a moment of crisis, having no pre-existing relationship with them, kind of like what they refer to in the world of retail sales as ‘cold calling.’ The ‘catcher,’ (the person in crisis) doesn’t know much, if anything, about what it is the ‘pitcher’ (the social worker) actually does in the hospital. The ‘student pitcher’ only knows that something is terribly wrong and that he or she needs to use growing social work skills to massage the situation for the best possible outcome under the circumstances. These circumstances might include time limitations, the lack of previous connection, constant interruptions by staff including doctors, nurses, phlebotomists, etc. The noise level is often high and there is no privacy most of the time. Of course, the interns are intimidated because they aren’t sure what to say. They think I have some magic pitch that always works and they’d love to borrow it to help overcome their natural discomfort.

More important, I counsel them, that learning a canned pitch is to learn the signs and symptoms of a faint –not just for the benefit of the patient or family but for their own benefit as well. The ER’s overwhelming smells alone are enough to induce a faint, a gag or even a vomit reflex –hardly the presentation of confidence that will successfully guide the intervention. As to the ‘magic pitch,’ of course I don’t possess one because the pitch isn’t formed until you see how the patient reacts when you enter the room. Then the feedback-loop begins and the social work stuff can enter into the process. If the patient sits up, makes eye contact and says hello it will be a lot easier to connect than if the patient is facing the wall, has his head covered up with a pillow and doesn’t acknowledge your arrival. As I always preach: start where the client is. A client covered by a bed sheet will be more difficult to engage than one who sits up and greats you openly.

If you have been reading my stories you will have seen that there are many ways to make that connection, and all of your life experiences will probably be more useful than anything you’ve learned in a social work textbook.

The social work textbook doesn’t say — when you enter a patient’s room and she is covered in a sheet — ‘just do ABC.’ Nope. ABC is yours to figure out. What would you get you to come out from under the sheet if you were the patient? To answer that question you might go on line and try to find an old copy of Thomas Gordon’s book, PET: Parent Effectiveness Training. When I was doing social work interventions in juvenile hall (where there were teenage equivalents of a ‘sheet over the head’) his advice was incredibly helpful. I’m also sure that none of the learned textbooks included the various forms of threats and intimidations available as adjuncts to the basic social work evaluations and interventions. I think the books are remiss, but I guess that’s why the schools send students into internships where they can actually watch practicing clinicians ply their craft instead of reading books and listening to lectures by tenured professors.

Here’s just one simple example of intimidation/threat I have used several times over the years. A patient comes to the ER with a suicide attempt/gesture, usually an O.D. or wrist-cutting. These signs of impulsivity usually emanate from desperation rather than a major depressive disorder. Those with a true major depressive disorder are more likely to really hurt themselves and a threat from me is not helpful. The issue here, aside from the patient’s psychiatric and medical needs, is the degree to which the patient is willing to cooperate with the evaluation. If I can’t get all the information I need, I can’t make a good evaluation. Sometimes that requires threatening behavior on my part.

The social worker should always read the patient’s complete medical chart and get any history of prior episodes of impulsive or self-destructive behavior. Then, when you go into the patient’s room you have the information you will need to figure out the best plan for the patient. The impulsive patient is often young, often angry and lacking insight. You should always allow the patient a chance to give a history of the events that brought him or her to the ER. While listening to this history, you are able to show empathy and understanding and perhaps get some idea of the person’s current insight and impulsivity.

Or not. If active listening and empathy don’t allow for the gathering of sufficient information and the patient looks like he/she will remain uncooperative, then it is time for the threat. It goes like this: “Look. I need you to cooperate with me. I’m concerned with your safety but you aren’t being open about your situation. My job is to decide whether you need to stay in the hospital or not. Right now, because you aren’t giving me the information I need to make that decision effectively, I’m going to admit you so that you don’t hurt yourself. What I’m going to do is go see a couple of other patients and then come back and see you. Your job, if you think you’re safe to go home, is to try and talk me out of my decision to admit you. Any questions?”

Usually, I don’t actually have to leave and come back after that threat, the patient responds to the threat immediately. I consider that a good sign.

Let me add this:  in thirty years, I did thousands of suicide evaluations and not one patient who I sent home ever killed himself or herself. I have sent patients home who eventually killed themselves but it was always after being in treatment or being evaluated by a subsequent mental-health professional. I’ve admitted patients who spent two weeks in the psychiatric part of the hospital then killed themselves after they were released. I’d say I made the right decision four to five thousand times, and part of that is because I was able to utilize threats and intimidation when such interventions were useful.

Let’s get back to the grad students and creativity. The second problem they often have is confronting violence and threats of it. I once had a female student who was a black belt in karate, and she was more adept at confronting violent behavior than most. The male students, and there were few of them, were more used to violence and were less uncomfortable confronting it. With all of my students, I required a thorough reading of the chart and a conversation with the patient’s nurse before going in to start the evaluation process. If there was any fear at all, the student was advised to take a male nurse or one of the male techs in the room as a back up.

I always advised them on safety issues: don’t close the door; don’t let the patient get between you and the door; if you sense violence, never present a large target to the patient; standing sideways reduces the strike zone by fifty percent — your vital organs are not openly exposed and neither are your eyes. If the patient is scaring people, then I advised the student to confront the patient about that directly by making a statement like: “I think you might have scared your nurse. Sometimes people who do that are scared themselves.” See what happens. Sometimes you can even ask the patient if they would be more comfortable in restraints. Many would.

In my career I was only struck one time. I went to interview an intoxicated, blind, eighty-four-year-old woman who had been acting-up at home. She was on the gurney facing away from me when the interview started. She had been calm since her arrival by ambulance, so my guard was down. She spoke softly, so I leaned over her shoulder and asked her if she would repeat what she had said and she literally blindsided me with an over the shoulder right-hook and got me right in the nose. It wasn’t a hard shot but a nose-shot doesn’t have to be hard.

Hope for the best. Plan for the worst.

Finally, students are often concerned about dealing with patients who have been disfigured by the violence of falls, traffic accidents, gunshots, pedestrians hit by trains, etc., and how they will respond to them. First, refer back to the beginning of this story. Learn how to recognize a faint. And believe that you will develop defenses against those olfactory, auditory and visual intrusions into your senses. A good social work preceptor should find a way to help that process along.

Like this:

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The trauma room had two beds. A female patient in bed one had been in a significant traffic accident. She was in an older car without airbags and there was speculation that she hadn’t used her seatbelt, since her body lacked the common pattern of bruising that goes hip to hip and shoulder to hip across the chest. In any case, her forehead struck the steering wheel and she suffered a typical avulsion injury, peeling the softer scalp back from the harder forehead, leaving the top of the skull exposed for all to see. The new social work intern had observed this from across the room while standing in the doorway. It isn’t just important for the students to recognize a faint coming on, it is equally important for the preceptor to keep an eye on the students in case they haven’t learned the fainting recognition skill yet. I did that just in time as she went from leaning on the door jamb to free-falling, and I grabbed her before she hit the ground, moving her to a chair nearby and putting her head lower than her heart. It was a simple faint and she came-to immediately. An hour later, when the patient had been stabilized and her avulsion stapled  back to the top of her head (yes, stapled) and all the blood was washed off, she looked much better.

I went in and switched the beds, telling the trauma nurse what I had done. I then asked the student to go into the trauma room and see the woman in bed two. Bed one was now empty and I was sure the student would be relieved to note that. I told her bed two had been in a minor accident and might want to contact her family.

Unaware of my ruse, the student went in, spent a few minutes and came to tell me the patient was fine and that someone had already contacted her family. She added that the patient seemed to have good coping skills and didn’t seem to need any interventions.

“Did she look familiar to you?” I asked.

“No. Why?”

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

“No.”

“Yes. It might help your faint reflex if you recognize that how they look when they get here is not how they will look when they leave. Your body lied to you and responded to a very temporary situation like it was permanent.”

Lesson learned. Class adjourned.

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Dividing line

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